This remedy may be prepared with golden shower tree (canafistula) bean pods and pineapple (pina) fruit rind spasms homeopathy generic rumalaya liniment 60ml overnight delivery. For diarrhea and intestinal parasites spasms toddler discount rumalaya liniment online master card, a tea is prepared with guajabo leaves and/or flowers combined with the leaves of coffee (cafe) muscle relaxant suppository generic rumalaya liniment 60ml visa, wild privet senna (sen) and wormseed (apazote) muscle relaxant herbal supplement purchase rumalaya liniment without a prescription. To treat skin disorders (including pano) muscle relaxant little yellow house discount 60ml rumalaya liniment with visa, the leaves are prepared as a decoction and used externally as a wash spasms heart rumalaya liniment 60ml discount. Availability: Dried leaves can be purchased from select botanicas (Latino/Afro-Caribbean herb and spiritual shops) in New York City muscle relaxant 5mg 60 ml rumalaya liniment with visa. Leaves are pinnately compound with 5-12 pairs of opposite leaflets which are oblong to oval in shape zopiclone muscle relaxant 60 ml rumalaya liniment mastercard, thin and papery in texture, fuzzy on the underside and rounded at the tip with a strongly asymmetric base and smooth leaf-edges. Fruits are leguminous seeds pods (10-17 cm long), oblong in shape with a longitudinal wing along the side of the opening and contain wedge-shaped, brown seeds (Acevedo-Rodriguez 1996). Distribution: this plant is most likely native to the South America, particularly the Orinoco and Amazon basins, but is naturalized throughout the tropics, including the Caribbean. It grows in moist, open areas, is somewhat uncommon and is sometimes cultivated in gardens (Acevedo-Rodriguez 1996). These side-effects included abdominal pain, diarrhea, dyspepsia and nausea (Thamlikitkul et al. For topical use, one clinical trial conducted in India reported that no negative side-effects were observed when the aqueous leaf extract was administered as a single application for the treatment of skin fungal infection (Domadaran & Venkataraman 1994). Animal Toxicity Studies: Animal studies have shown that this plant is relatively safe and non-irritating when applied topically and has not shown toxic effects when administered orally. No evident clinical signs of adverse effects were observed in rabbits when an aqueous extract of the fresh leaf (20%; macerated for 1 hour) was applied (0. In mice, no signs of toxicity were observed when the hydroalcoholic leaf extract (10 g dry plant/kg body weight) was administered orally and subcutaneously (Mokkhasmit et al. Results of histopathology studies did not reveal any organic damage, so this extract was determined to be nontoxic in this study (Martinez, Morejon, Lopez et al. Contraindications: Contraindicated in patients with: intestinal obstruction (due to stimulation of peristalsis), gastrointestinal inflammatory disease (due to potential irritation), anal prolapse (due to aggravation of bowels actions), hemorrhoids (due to potential induction of prolapse, stenosis and thrombosis), pregnancy (may cause endometrial stimulation although shown to be safe during pregnancy in human clinical trial), lactation (due to potentially genotoxic and mutagenic constituents), children under age 12 (due to potential dehydration), extended use (due to damage) and abdominal pain or appendicitis of unknown origin (due to the possibility of rupturing by contracting an inflamed organ; Brinker 1998). Drug Interactions: Diuretics (may aggravate potassium loss if co-administered), cardiac glycosides (if herb is over-used or misused, may increase the toxicity of these drugs; Brinker 1998). Leaves and leaf extracts of this plant have demonstrated the following pharmacological effects in laboratory and animal studies: adherence inhibition, anti-inflammatory, antimicrobial, antiplatelet and dermatophilosis improvement (see Laboratory and Preclinical Data table below). Biologically active compounds identified in this plant include: aloe emodin, chrysophanol, emodin and rhein; and in the leaf include: chrysarobin, dihydroxymetholanthraquinone, rhein glycoside and tannin. For skin infections, pimples or bumps (granos) on the skin, chop 50 grams of the leaf (15-20 small leaves) and add them to 1 liter (4 cups) of boiled water; let it sit for 12 hours to infuse; and use this decoction to wash the affected area 2-3 times per day (note: this preparation will not keep for more than 24 hours and should be prepared fresh daily). For skin fungal infections: wash the affected area with soap and water, wash the laves, crush them to make a poultice and apply 1 spoonful 263 (5 grams) of this vegetal matter topically on the affected area; cover with a bandage or clean cloth and change 3-4 times daily (Germosen-Robineau 2005, Giron 1988). Clinical Data: Senna alata Activity/Effect Preparation Design & Model Results Reference Constipation Leaf infusion (120 Multicenter Showed significant Thamlikitkul et treatment mL) administered at randomized laxative effect (P < al. Treatment of bovine dermatophilosis with Senna alata, Lantana camara and Mitracarups scaber leaf extracts. Antiinflammatory activity of heat-treated Cassia alata leaf extract and its flavonoid glycoside. Thamlikitkul V, Bunyapraphatsara N, Dechatiwongse T, Theerapong S, Chantrakul C, Thanaveerasuwan T, Nimitnon S, Boonroj P, Punkrut W, Gingsungneon V et al. Traditional Preparation: Typically the leaves are prepared as a tea by infusion or decoction for a short period of time. Traditional Uses: For the common cold or flu, a tea is prepared using the leaves of guanabana combined with cinnamon (canela) bark, acerola cherry (cereza) leaves and bitter orange (naranja agria) leaves. Guanabana leaves are used to support recovery from musculoskeletal injury, typically prepared as a tea in combination with lemongrass (limoncillo) leaves, sweet orange (naranja) leaves and lime/lemon (limon) fruit. For menopausal hot flashes, a tea is prepared of the leaves and is considered a relaxant, often combined with the leaves/stalk of lemongrass (limoncillo). To calm down anxiety and nerves (los 266 nervios), a sedative tea is prepared of the leaves along with lemon/lime (limon) or sweet orange (naranja) leaves and taken internally. The fruit is thought to be cold (frio) or cooling (fresco) and is used as a diuretic and to lower fever. Healers consider the leaves of this plant to be potentially toxic if taken in large doses, so caution is advised and only small to moderate amounts of the tea should be taken internally. To avoid extracting too many toxins from this potent plant, herbalists advise that the leaves be boiled only for a very short period of time when preparing a tea/decoction. Herbalists contraindicate eating the fruit during pregnancy or menstruation because it is attributed very cold properties which could cause complications such as menstrual cramps, the accumulation of phlegm and mucha frialdad en la matriz (lots of coldness in the womb). Availability: Fruits are available in season on a limited basis (as they are highly perishable) at ethnic grocery stores, food markets and fruit stands in Latino/Caribbean neighborhoods. Dried leaves can be purchased from botanicas that specialize in selling Caribbean medicinal plants. Leaves are alternate and narrowly oval (6-17 cm long) with a thin, papery texture, shiny surface and smooth leaf edges that curl up slightly. Fruits are fleshy and shaped like a rounded or elongated heart (15-30 cm long) with green skin and covered with small bumps or lumpy spine-like projections. Seeds are numerous, dark brown and surrounded by a tart, white pulp (Acevedo-Rodriguez 1996). Distribution: Native to tropical America, this plant grows in the Caribbean and is often found in disturbed areas (Acevedo-Rodriguez 1996). Potentially neurotoxic compounds have been identified in the leaves and other parts of Annona muricata and other members of the plant family Annonaceae; however, these compounds were not detected in the fruit pulp or seeds. Uptake and accumulation of these benzylisoquinoline derivatives in the brain may be related to the high incidence of atypical levodopa-resistant Parkinsonism and progressive supranuclear palsy in Guadeloupe in the French West Indies (Kotake et al. Animal and Laboratory Toxicity Studies: No mortality was observed in mice given 1-5 g/kg of the aqueous decoction orally (Saravia 1992). The leaves administered orally to rats resulted in fibrosarcomas, and the topical application in hamsters caused skin cancer development (OGara et al. Plants in the family Annonaceae have been shown to contain annonaceous acetogenins which are powerful, lipophilic complex I inhibitors. Annonacin has been shown to be toxic to mesencephalic dopaminergic neurons by impairing energy metabolism (Lannuzel et al. These results suggests that ingestion of Annonaceae plants may play a role in the development of Guadeloupean Parkinsonism (Champy et al. Results suggest that alkaloids from Annona muricata can modulate the function and survival of dopaminergic nerve cells and could conceivably cause neuronal dysfunction and degeneration after repeated consumption (Lannuzel et al. The edible portion of the fruit (the white pulp) is a source of potassium and vitamins B1, B2 and C (U. Laboratory and Preclinical Data: Annona muricata Activity/Effect Preparation Design & Model Results Reference Antioxidant Ethanol extract of In vivo: albino rats Inhibited cold Padma et al. Possible relation of atypical parkinsonism in the French West Indies with consumption of tropical plants: a case-control study. Annonacin, a lipophilic inhibitor of mitochondrial complex I, induces nigral and striatal neurodegeneration in rats: possible relevance for atypical parkinsonism in Guadeloupe. Proliferative lesions in check and esophagus of hamster treated with plants from Curacao. Muricoreacin and murihexocin C, mono-tetrahydrofuran acetogenins, from the leaves of Annona muricata. Kotake Y, Okuda K, Kamizono M, Matsumoto N, Tanahashi T, Hara H, Caparros-Lefebvre D, Ohta S. Detection and determination of reticuline and N-methylcoculaurine in the Annonaceae family using liquid chromatography-tandem mass spectrometry. Journal of Chromatography B: Analytical Technologies in the Biomedical & Life Sciences 806(1):75-8. Toxicity of Annonaceae for dopaminergic neurons: potential role in atypical parkinsonism in Guadeloupe. The mitochondrial complex I inhibitor annonacin is toxic to mesencephalic dopaminergic neurons by impairment of energy metabolism. Effect of alcohol extract of Annona muricata on cold immobilization stress induced tissue lipid peroxidation. Effect of the extract of Annona muricata and Petunia nyctaginiflora on Herpes simplex virus. Five novel mono-tetrahydrofuran ring acetogenins from the seeds of Annona muricata. Recherche de quelques activites pharmacologiques traditionnelles dAnnona muricata et dAnnona reticulate chez lanimal. Traditional Uses: the beans (pigeon peas) of this plant are used for nutrition and nourishment and prepared as a part of Dominican culinary traditions. For arthritis and joint pain, the leaf is applied locally to the affected area to relieve pain and inflammation. To induce abortion, the root of this plant is boiled to make a strong decoction and taken internally as a tea. In the Caribbean, this plant is used to treat toothache and conjunctivitis (Germosen-Robineau 1995). Availability: Dried roots can be purchased from select botanicas in New York City. Beans can be purchased from grocery stores and supermarkets, especially in Latino and Caribbean neighborhoods. On the underside, leaves have yellow spots, resinous dots and are covered with whitish, woolly hairs. Flowers are yellow and red, grow in loose clusters at the 271 tip of the stem and have bracts and sepals covered with short, rust-colored, wooly hairs. Fruits are oblong bean pods covered with short, soft, gland-bearing hairs and are slightly constricted around the seeds which are green, turning light brown as they mature (Acevedo-Rodriguez 1996). Distribution: Thought to be native to Africa, this plant is an important grain legume that is widely cultivated throughout the tropics and primarily produced in India (Acevedo-Rodriguez 1996). No data on the safety of the leaves or root in humans has been identified in the available literature. Animal Toxicity Studies: In rats, the whole plant administered intraperitoneally resulted in toxic effects at 100 mg/kg and at 112. Guandul has shown the following effects in preclinical studies: antimalarial (Yarnell et al. Cajanone, an isoflavone from the seed and root, has demonstrated antimicrobial and antifungal properties (Dhar et al. Phenylalanine is the active constituent responsible for the antisickling effects of the seed extract (Ekeke & Shode 1990). In addition to hypoglycemic properties, the seed has demonstrated activity in restoring erythrocyte morphology in blood samples from individuals with sickle-cell anemia (Iwu et al. Cajanus cajan is recognized by the Pharmacopeia of Oriental Medicine, 1968 edition (Penso 1980). Compounds identified in the plant include: 2hydrozygenistein, cajanone and ferreirin; root: 2 0methylcajanone, alpha-amyrin, cajaflavanone, cajaisoflavone, cajaquinone, geinstein, isogenistein-7-0glucoside, lupeol; and seed: cajanin and concajanin (Duke & Beckstrom-Sternberg 1998). The cooked beans are high in potassium and phosphorus, contain moderate amounts of calcium and magnesium and have a low content of iron, zinc, copper and manganese (Nwokolo 1987). The raw beans also contain significant amounts of vitamins B1, B2, B3, B5 and B6 (U. To validate the efficacy of traditional use, more research is needed on the antiinflammatory and analgesic effects of the leaf (Germosen-Robineau 1995). Laboratory and Preclinical Data: Cajanus cajan Activity/Effect Preparation Design & Model Results Reference Antibacterial & Dry leaf extract; 50 In vitro Active against Bacillus Boily & Van antituberculosis mg/mL dose subtilis, Staphylococcus Puyvele 1986 aureus & Mycobacterium smegmatis Antimicrobial Leaf decoction In vitro Active against strains of Kambu et al. Screening of medicinal plants of Rwanda (Central Africa) for antimicrobial activity. Phenylalanine is the predominant antisickling agent in Cajanus cajan seed extract. Evaluation de lactivite animicrobienne de quelques preparations traditionnelles antidiarrheiques utilesees dans la ville de Kinshasa-Zaire. The kinetics of reversal of pre-sickled erythrocytes by the aqueous extract of Cajanus cajan seeds. Traditional Preparation: the seed pods are typically prepared as a gargle or mouth rinse by decoction and are also used as a tea, mouth rinse and vaginal wash. Traditional Uses: Guatapanal is most popularly known as a remedy for sore throat and tonsillitis. A decoction of the dried fruits, seeds or fruit husk is prepared by boiling in water and taken as a gargle a few times daily while symptoms persist. Sometimes this gargle preparation is also made with additional ingredients, such as Caribbean pine (cuaba) and bicarbonato (sodium bicarbonate or baking soda). Oral administration of the fruit decoction is said to lower fever and decrease inflammation and infection. For toothache, mouth and gum inflammation or oral infections, the fruit is boiled with coffee (cafe) and salt to prepare a mouth rinse. The fruits are also used to make a douche (lavado vaginal) for vaginal or ovarian infections, inflammation and swelling; pain in the reproductive organs; menstrual disorders; sexually transmitted infections; and to cleanse the reproductive system. This vaginal wash is sometimes prepared with powdered Massengill, an over-the-counter drug from the pharmacy, together with guatapanal; when combined, this pharmaceutical product is said to get rid of the bacteria while the herb works by removing the infection and inflammation. Availability: Dried seed pods can be purchased from select botanicas (Latino/Afro-Caribbean herb and spiritual shops) in New York City. Leaves are feathery and twice divided with 9-17 secondary leaf axes each with 16-24 pairs of tiny, rounded leaflets. Flowers are light yellow to whitish with 5 petals and grow in short clusters at the leaf bases. Fruits are light brown, hard bean pods (3-6 cm long) turning dark reddish brown when mature; they are often concave, curved in a circular form or S-shaped (Little et al. Distribution: this plant grows in the Caribbean and Central America and is cultivated in tropical regions of the world (Little et al. Phytochemistry studies have shown the fruits of this plant to contain gallicand ellagen-tannic acids which decompose upon hydrolysis into water and ellagic acid (Loewe 1875 in Felter & Lloyd 1898). These compounds are known to have astringent properties suggesting their therapeutic potential in treating conditions such as diarrhea, sore throat and mucous membrane inflammation. No information has been found on the safety, adverse effects, contraindications, herb-drug interactions or indications and usage of this plant. A closely related species, Caesalpinia bonducella (also commonly called divi-divi) is used in a similar manner: the roasted seeds are taken as a febrifuge and anti-inflammatory agent in India and South America. See medicinal plant entry for Brasil for information on this and other species of the plant genus Caesalpinia (Gruenwald et al. This plant is important commercially because of the high concentration of tannin and gallic acid in the pods which are used for tanning leather. Traditional Preparation: Typically prepared as a tea by decoction or infusion and taken internally; may also be added to complex herbal mixtures and prepared as a decoction or tincture, extracted in alcohol. The root is a common ingredient in herbal remedies prepared with mixtures of multiple plants (bebedizos and botellas) for womens reproductive health conditions. It is often used for complications associated with childbirth and pregnancy 276 and can be taken as a remedy for labor pain and to support postpartum recovery. For vaginal or urinary tract infections, a tea is made of the root of guauci and is sometimes combined with Spanish clover (amor seco) to cleanse the reproductive system and to treat kidney disorders. Availability: Dried roots can be purchased from botanicas that specialize in supplying Caribbean medicinal plants. Distribution: this plant grows in open and disturbed areas in the Caribbean and is widely distributed throughout tropical and subtropical America (Acevedo-Rodriguez 1996). Other plant constituents include: beta-sitosterol, campesterol, hentriacontane, nonacosane and stigmasterol (Duke & Beckstrom-Sternberg 1998). Laboratory and Preclinical Data: Ruellia tuberosa Activity/Effect Preparation Design & Model Results Reference Antibacterial Fractions: In vitro: Gram Active; methanol & ethyl Wiart et al. Traditional Preparation: this plant is typically prepared as a tincture, extracted in alcohol or boiled in water as a decoction and applied externally. Traditional Uses: the sticks (los palos), branches and wood (madera) of this plant are prepared as a tincture in gin (ginebra) and used for the treatment of upper or lower respiratory tract infections, skin disorders, arthritis and sexually transmitted infections. For arthritis (reumatismo), rub the tincture externally on the affected area and take 1-2 spoonfuls per day internally. To prevent hair loss, the wood is boiled in water to prepare a decoction that is then applied topically to the scalp. Availability: Can be purchased from some botanicas that specialize in selling medicinal plants. Leaves grow in opposite pairs along branches and are pinnately compound with 1-3 pairs of opposite, oval to oblong leaflets. Fruits are yellowish-orange, flattened capsules which open to reveal hanging seeds surrounded by a bright, scarlet red, fleshy aril (Acevedo-Rodriguez 1996). Distribution: this plant is native to tropical America and grows in the Caribbean. It can occasionally be found in dry coastal forests and is sometimes cultivated (Acevedo-Rodriguez 1996). However, cases of skin rashes subsequent to herb intake have been reported and potential adverse reactions of excess use or high dosages include diarrhea, grastrointestinal inflammation (gastroenteritis) and intestinal colic (Gruenwald et al. Aqueous extracts of a closely related species, Guaiacum coulteri, have shown significant hypoglycemic activity in vivo in rabbits with experimentally-induced diabetes and hyperglycemia (Roman Ramos, Lara Lemus et al. Major chemical constituents that have been identified in species of the Guaiacum genus include the following: cresol, essential oil, furoguaiacidin, furoguaiacin, furoguaiaoxcidin, guaiacene, guaiacol, guaiaconic acid, guaiagutin, guaiaretic acid, guaiasaponin, guaiazulene, guaiene, guaiguttin, guaiol, guaioxide, hydroguaiaretic acid, meso-dihydroguaiaretic acid, officigenin, resin, saponin, tannin and vanillin (Duke & Beckstrom-Sternberg 1998). Guaiacum can be administered as an infusion, decoction, tincture or various commercial preparations including ointments and drops. Average daily dosage is 4-5 g of the powdered wood or 20-40 drops of the tincture. Laboratory and Preclinical Data: Guaiacum officinale Activity/Effect Preparation Design & Model Results Reference AntiAqueous ethanolic In vivo: rats with Active at 200 mg/kg in Duwiejua et la. Anti-inflammatory activity of Polygonum bistorta, Guaiacum officinale and Hamamelis virginiana in rats. Note: In New York City, the common name hierba mora may also be used for other species in the genus Solanum, including Solanum dulcamara L.
Post-infectious encephalomyelitis is an acute muscle relaxant eperisone hydrochloride buy rumalaya liniment 60 ml otc, inflammatory spasms during period order rumalaya liniment, demyelinating disease affecting multiple levels of the central nervous system (brain muscle relaxant leg cramps buy rumalaya liniment 60 ml without prescription, optic nerves gut spasms buy rumalaya liniment online pills, and spinal cord) and occurs after a respiratory tract infection spasms knee discount rumalaya liniment 60 ml otc, viral exanthem muscle relaxant gas rumalaya liniment 60 ml generic, or an immunization spasms below left rib cage generic 60 ml rumalaya liniment fast delivery. Occurrence is rare before 1 year of age spasms movie rumalaya liniment 60 ml mastercard, and it accounts for 10-15% of acute encephalitis cases in the United States (1) with peak incidence at 5 to 6 years of age. Worldwide there are over 100,000 cases that occur secondary to measles infection (5). Page 208 Viral encephalitis can be transmitted in one of two ways: via animal or insect vectors that transmit viruses maintained in environmental reservoirs or by human transmission via direct contact with human blood or body fluids. Epidemiologically, this is important since environmentally derived viral pathogens display relatively uniform epidemiologic characteristics. Furthermore, human disease correlates with the life cycle of the vector (spring and summer) and exhibits a geographic distribution that parallels with the habitat of the vector. In contrast, viruses transmitted human-to-human display few seasonal, temporal, or geographic predilections. For example, mumps is very highly neuroinvasive, but its neurotropism appears limited to ependymal cells, which may account for the low level of neurovirulence. Transmission of virus into the brain through neural pathways include 1) bidirectional axonal transport, and 2) cell-tocell infection (6). Post-infectious encephalitis is likely an autoimmune cell-mediated immune process characterized by perivenulitis and contiguous demyelination (1) caused by derangement and dysregulation of the immune system following either respiratory or intestinal tract infections. These cells may activate other mediators of inflammation, including inflammatory cytokines that trigger demyelination. Apnea, focal or generalized seizures, paralysis, or coma may appear with progressive neonatal herpes simplex encephalitis. The risk of transmission from mother to fetus is 30-50% with maternal primary infection, as compared with <3% with recurrent infection (4). In older children, the clinical manifestations of the inflammatory response are initially subtle and diverse. Basal ganglia involvement may lead to movement disorders and brainstem involvement may lead to cranial nerve dysfunction. Initial symptoms include: fever (always present) with headache, vomiting, malaise, behavioral changes, and speech difficulties. Focal neurological signs, such as hemiparesis, dysphagia, or visual field defects develop and likely reflect selective involvement of the temporal or frontal lobes. The clinical course, however, may become more chronic and result in seizures, memory loss, and behavioral disturbances. Clinical manifestations of acute encephalitis include: fever, headache, altered consciousness, and seizures, including status epilepticus. The virus is maintained in the wild through a mosquito and small woodland mammal (chipmunks, rabbits, and squirrels) cycle. Louis encephalitis, the transmission cycles do not involve an avian reservoir (6). There are Page 209 approximately 100 cases per year in children 5 to 11 years of age. Lethargy, behavioral changes, and/or brief seizures follow with clinical improvement over a 7 to 8 day period. Fifty percent develop seizures and 10 to 15% of children develop status epilepticus. The virus is maintained in a bird-vertebrate cycle involving Culex tritaeniorhynchus mosquitoes that breed in rice fields, domestic pigs, young water buffalo, herons and other wading birds (1,6). Infection of the basal ganglia and thalamus presents as tremors during the acute disease and result in parkinsonian mask-like facies, rigidity, tremor, and dystonia in survivors (4). Mortality ranges from 25 to 40% with the majority of survivors having mental retardation, seizures, motor deficits, or subtle behavioral and intellectual abnormalities. Eastern equine encephalitis virus has the lowest incidence in North America, but has the highest mortality rate. Geographically, the eastern encephalitis virus is found in the eastern half of the United States primarily along the freshwater marshes of the Atlantic and Gulf coasts from Massachusetts to Florida. Only with alterations in the conditions of the marshes, changes in rainfall, different bird populations, and variations in mosquito breeding, can the virus spill over into other mosquito vectors that feed on mammals. The Asian Tiger mosquito (Aedes albopictus) was imported into Houston, Texas in 1985 in a shipment of used tires. In 1991, Eastern encephalitis virus was recovered in the Asian Tiger mosquito and has raised major concerns since the mosquito is an aggressive biter of humans which thrives in suburban and forest habitats and could become a treacherous host for the eastern encephalitis virus (6). The differential diagnosis for acute encephalitis includes: bacterial meningitis, Rocky Mountain spotted fever, brain abscesses, drug intoxication, lead encephalopathy, Reyes syndrome, hepatic coma, uremia, organic acidemias, amino acidemias, urea cycle defects, intracranial neoplasms, systemic lupus erythematosus, cerebrovascular accidents, pseudotumor cerebri, trauma, and post-infectious encephalopathies. The presence of fever is helpful in distinguishing encephalitis from encephalopathies due to toxins or inborn errors of metabolism. Finally, acute and convalescent serum antibody titers generally take 3 to 6 weeks to develop. In contrast, neonatal herpes simplex encephalitis in the acute stages reveals diffuse brain edema that is consistent with the hematogenous transmission of the virus to the brain. The definitive diagnostic test of encephalitis, however, is brain biopsy for tissue histology and culture. Antivirals inhibit viral infection by binding with viral nucleic acid and prevent viral replication. Generally, improvement occurs over days to weeks, while focal deficits resolve over a period of months. Significant neurological sequelae are more likely to occur if the patient presents with lethargy, coma, or with seizures. In contrast, La Cross encephalitis has the lowest mortality, but seizures develop in 10% of survivors (2). Chapter 32 Meningitis, Infectious Encephalopathies, and Other Central Nervous System Infections. She is weak, poorly responsive and sick (toxic) appearing with occasional grunting. You are worried about meningococcal disease and explain to her parents that you must start parenteral antibiotic treatment and fluid replacement immediately. You place an intraosseous needle and administer fluids, pressor medications and ceftriaxone (a third generation cephalosporin). Despite these measures, she continues to deteriorate, developing large purpuric lesions on her lower extremities. Most of the purpuric lesions have regressed but she develops necrosis of the 4th and 5th toes of her right foot, which requires amputation. It is classically said that, patients are well at 12 oclock and dead by 3 oclock. Each year, sepsis develops in more than 500,000 people in the United States with a mortality rate of 35-45% in adults (1). Sepsis is estimated to be the 13th leading cause of death overall in patients older than 1 year of age. There are several definitions used to describe the conditions associated with sepsis (1-3): Bacteremia (or fungemia) is the presence of viable bacteria (or fungi) in the blood. Septicemia is a systemic illness caused by the spread of microbes or their toxins via the blood stream. Streptococcus pneumoniae, Neisseriae meningitidis, Staphylococcus aureus, and group A streptococci are major causes of sepsis in children beyond the newborn period. Although the infection is an essential part of the development of sepsis, the septic response occurs when immune defenses fail to contain the invading microbe(s). Sepsis due to gram negative microorganisms and endotoxic shock are major triggers for the septic syndrome. Gram positive microorganisms, especially Staphylococcus aureus can elaborate exotoxins, which appear to act through a similar signal pathway to that of endotoxins, triggering the release of inflammatory mediators. How these signals initiate inflammation and how the host responds to them are active areas of research. Moreover, vascular integrity may be damaged by neutrophil enzymes (such as elastase) and toxic oxygen metabolites so that local hemorrhage ensues (4). Nonspecific mental status changes and hyperventilation are often the early findings in older children and adults. Cholestatic jaundice with elevated levels of serum bilirubin (mostly conjugated) and alkaline phosphatase may precede the other signs. While most patients have fever, some have a normal temperature or are hypothermic. Other skin lesions such as ecthyma gangrenosum (Pseudomonas aeruginosa), petechial rash (meningococcemia, rarely H. Cardiac output is initially normal or increased (the "hyperdynamic phase") in sepsis and helps in distinguishing septic shock from other types of shock. Buffy-coat smear of peripheral blood is a quick and inexpensive method and can assist in more effective therapy; however it is not very sensitive. Other diagnostic labs and a lumbar puncture may be delayed so that antimicrobial treatment can be started immediately in critically ill patients. Severe coagulopathy, as frequently seen in meningococcemia, may also delay lumbar puncture because of the risk of spinal epidural hematoma and bleeding. Recently, several polymorphisms in genes coding for key inflammatory molecules have been identified and suggested as a risk factor in sepsis and adverse outcomes. Depression of cardiac function (diminished contractility) develops within 24 hours in most patients with advanced sepsis. Cardiovascular support using inotropic medications such as dopamine, dobutamine, and possibly epinephrine, is necessary in almost all patients with severe sepsis. Empiric antimicrobial therapy should be initiated as soon as blood and other relevant sites are cultured. However, difficulty obtaining cultures should not delay antibiotic administration which must be started as soon as possible. The immune status of the patient, the underlying condition (including illicit injecting drug abuse, splenectomy) are important in deciding the appropriate treatment. Removal of indwelling intravenous catheters and removal or drainage of a focal source of infection are essential. In areas with increased pneumococcal or staphylococcal resistance or for patients who have received frequent antibiotic therapy (sickle cell anemia) vancomycin can also be started for suspected gram positive infections Despite aggressive management, many patients with severe sepsis or septic shock will die. Which of the following is not an immediate priority in the resuscitation phase of a child in septic shock (2) Which of the following skin examination findings is generally not associated with sepsis Inflammation, coagulopathy, and the pathogenesis of multiple organ dysfunction syndrome. On the fourth day of illness, he had edema to his hands and feet with a diffuse red-purple discoloration over the palms and soles. His bulbar conjunctivae are injected with limbal sparing (less injected around the limbus where the cornea fuses with the conjunctiva), but no exudates. He has some mild edema of his hands and feet with some red-purple discoloration of the palms and soles wrapping partially around the dorsum with a sharp demarcation at the wrists and ankles. He has a generalized deeply erythematous rash which is flat with irregularly shaped pink-red lesions ranging from 1 to 7 cm in diameter, with some areas coalescing. His fever defervesces after 24 hours with improvement in his rash, lips, extremities and conjunctivae. Tomisaku Kawasaki of Tokyo, Japan in 1967, it occurs in all regions of the world among children of diverse ethnicity. The clinical criteria he described remains the basis of all clinical and epidemiologic descriptions used today (see Table 1). Fifty percent of patients are younger than 2 years of age and 80% are younger than 4 years (1). In Hawaii, the rate for children of European ancestry is 9 per 100,000 per year; for children of African-American ancestry 20 per 100,000 per year; and for children of Japanese and Korean ancestry 145 per 100,000 per year (1). The acute phase (first 10 days of illness) is characterized by an intense inflammatory infiltrate in the vasa vasorum of the coronary arteries with infiltration and hypertrophy of the intima. Some patients may develop congestive heart failure and myocardial dysfunction, but death during this phase is usually sudden and thought to be due to arrhythmia. Fragmentation of internal elastic lamina and damage to the media can result in aneurysm formation. Death during this stage most often occurs from acute myocardial infarction or chronic myocardial ischemia. With recognition of serious sequelae if therapy is delayed, we now stress making the diagnosis as early as possible, disregarding the 5 day provision. In untreated patients, the mean duration of fever is 11 days with a range of 5 to 33 days. The eye involvement consists of discrete vascular injection of the bulbar conjunctiva most marked in the periphery with relative sparing around the limbus (known as limbic or perilimbic sparing). Mouth changes include initial bright red erythema of the lips (progressing to swelling, cracking and bleeding), prominent papillae on the tongue with erythema (strawberry tongue), and diffuse erythema of the oropharynx without vesicles, ulcers or erosion. The rash can takes many forms (which is why the term "polymorphous" is used) but it is never vesicular or bullous. The most common form is deeply erythematous with papules varying from 2-3 mm to large, coalescent plaques covering several centimeters. Occasionally the cervical adenopathy can be diffuse and massive, even causing tracheal shift. During the first week of illness, arthritis was usually polyarticular of large and small joints. Oligoarthritis of large weight bearing joints was noted more in the second week of illness. Severe abdominal pain, often associated with diarrhea can be seen in the first few days of illness. Liver involvement occurs in 40% of patients, including liver enzyme and bilirubin elevations. Gallbladder hydrops can be seen with elevated bilirubin levels and findings of a right upper quadrant mass. Echocardiography may demonstrate some degree of myocardial involvement in the majority of patients. Progressive dilatation and aneurysm formation may occur with a peak incidence and severity at approximately 1 month after the onset of disease. Approximately 2/3 of children with aneurysms at 8 weeks post onset have regression by 1 year on echocardiography. Children with coronary abnormalities are at high risk for myocardial infarction, sudden death, coronary thrombosis, and myocardial ischemia within the first year after onset and have a higher lifetime risk in the long term. Progression to significant coronary stenosis with resultant myocardial ischemia occurs in a very high percentage over the next 20 years. Aneurysms in vessels other than the coronary arteries, such as axillary, mesenteric, and renal arteries have been noted in severe cases. By day 10, nearly all have elevated platelet counts which may peak at 650,000 to 2,000,000 per cubic mm between days 10 and 20. Liver enzymes are moderately elevated (over twice the upper limit of normal) in 40% of patients in the first week. These patients may be initially diagnosed with lymphadenitis and are treated with antibiotics. In the United States, a dose of 100 mg/kg to a maximum of 4 grams per day is given until a few days after defervescence or until the 14th day of illness. Aspirin has been shown to result in a more rapid defervescence, lower frequency of relapse of fever and shorter hospital stay. Presence of fever ranging between 38 and 41 degrees C, and four out of five principal diagnostic criteria which include: discrete conjunctival injection without exudates, changes in the mouth, polymorphous erythematous rash, changes in the hands and feet, and unilateral cervical lymphadenopathy. She is an ill-appearing adolescent female who is poorly oriented to her surroundings and only responds to questions with much coaxing, and her answers are incoherent. The illness was associated with the isolation of Group 1, type 29 staphylococci from skin, abscesses, empyema fluid or mucous membranes, and Todd named the disease "toxic shock syndrome" (1). One brand was removed from the market and all tampons containing superabsorbent polyacrylate fibers were removed in 1985. All staphylococcal strains isolated by Todd elaborated a previously undescribed epidermal toxin which produced a cleavage at or below the basal layer of the skin. Unlike exfoliatin, this new toxin was inactivated by heating to 60 degrees C for 30 minutes and was neutralized by staphylococcal antitoxin, but not by exfoliatin antitoxin (1). It belongs to a large family of toxins called pyrogenic toxin superantigens which are potent stimulators of the immune cell system. Serologic tests for Rocky Mountain spotted fever, leptospirosis, or measles are negative. A case is classified as confirmed if all six of the clinical findings described above are present, including desquamation, unless the patient dies before desquamation occurs. The focus of the staphylococcal infection may appear surprisingly normal or may have only minimal signs of inflammation or purulence, such as with impetigo or paronychia. The toxin interferes with the release of inflammatory mediators, so signs of inflammation may be absent (2). The differential diagnosis of a severe systemic illness with fever and erythematous rash includes: invasive group A streptococcal diseases, Staphylococcal toxin-mediated diseases, septic shock of other bacterial etiologies including meningococcemia, scarlet fever, Rocky Mountain spotted fever, Kawasaki syndrome, leptospirosis, measles, systemic lupus erythematosus, Stevens Johnson syndrome, Epstein-Barr virus, adenovirus infection, enterovirus infection, human parvovirus B19 infection, Yersinia pseudotuberculosis infection (Izumi fever), drug reactions, juvenile rheumatoid arthritis, polyarteritis nodosa, Reiters syndrome, mercury poisoning, etc. Additionally, antiribosomal antibiotics such as clindamycin inhibit protein synthesis which may reduce the rate of toxin excretion. There may be permanent cognitive impairment, such as memory loss, distractibility, emotional or personality alteration, and persistently cyanotic extremities (2,3). Additionally, some physicians prescribe prophylactic antibiotics to these women during menstruation. The serious consequences of staphylococcal and streptococcal toxic shock syndromes demand early recognition of symptoms and aggressive treatment.
The National Stockpile Radiation Working Group published recommendations for the medical management of acute radiation syndrome in 2004 spasms just below sternum order online rumalaya liniment. However muscle relaxant clonazepam order genuine rumalaya liniment online, the dosing muscle relaxant gabapentin buy rumalaya liniment 60ml cheap, safety and efficacy are not clearly established and it is not a standard of care for transplant patients muscle relaxant flexeril buy rumalaya liniment 60 ml without a prescription. Recombinant human granulocyte-colony stimulating factor: in vitro and in vivo effects on myelopoiesis spasms caused by anxiety rumalaya liniment 60 ml otc. Approve Neupogen if prescribed by infantile spasms 6 months old discount rumalaya liniment 60 ml amex, or in consultation with spasms leg purchase rumalaya liniment 60ml mastercard, an oncologist or hematologist muscle relaxant food purchase rumalaya liniment on line amex. Neupogen is indicated to decrease the incidence of infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelosuppressive anticancer drugs associated with a clinically significant incidence of febrile neutropenia. The use of granulocyte colony-stimulating factor to increase the intensity of treatment with doxorubicin in patients with advanced breast and ovarian cancer. Reduction by granulocyte colony-stimulating factor of fever and neutropenia induced by chemotherapy in patients with small-cell lung cancer. Treatment of chemotherapy-induced neutropenia by subcutaneously administered granulocyte colony-stimulating factor with optimization of dose and duration of therapy. Granulocyte colony-stimulating factor and neutrophil recovery after high-dose chemotherapy and autologous bone marrow transplantation. The colony stimulating factors: discovery, development, and clinical applications. Acute myeloblastic leukaemia and recombinant granulocyte colony stimulating factor. Granulocyte colony-stimulating factor and granulocyte-macrophage colony-stimulating factor. Effect of granulocyte colony stimulating factor on neutropenia induced by cytotoxic chemotherapy. Hematologic effects of recombinant human granulocyte colony-stimulating factor in patients with malignancy. Randomized study of recombinant human granulocyte colony-stimulating factor after high-dose chemotherapy and autologous bone marrow transplantation for high-risk lymphoid malignancies. Filgrastim in patients with chemotherapy-induced febrile neutropenia: a double-blind, placebo-controlled trial. Prophylactic administration of granulocyte colonystimulating factor (Filgrastim) after conventional chemotherapy in children with cancer. Granulocyte-colony stimulating factor (filgrastim) accelerates granulocyte recovery after intensive postremission chemotherapy for acute Requests for continuing therapy that were approved by a previous Health Plan will be honored for at least 30 days upon receipt of documentation demonstrating that approval myeloid leukemia with aziridinyl benzoquinone and mitoxantrone: Cancer and Leukemia Group B study 9022. Documentation that at least one of the following non-pharmacologic interventions has been tried but has not been successful: a. Emtriva[emtricitabine] or Viread [tenofovir] to Truvada [emtricitabine/tenofovir] or vice versa) References 1. Idiopathic thrombocytopenic purpura: a practice guideline developed by explicit methods for the American Society of Hematology. Guidelines for the investigation and management of idiopathic thrombocytopenic purpura in adults, children and in pregnancy. Recent advances in the treatment of chronic refractory immune thrombocytopenic purpura. Patient has failure, intolerance or contraindication to one of the following immunosuppressants: azathioprine, cyclophosphamide, or methotrexate. For Eosinophilic Asthma: the patient has responded to Nucala therapy as determined by the prescribing physician. Member must have a trial a failure of two different preferred products (list below) i. Members ages 10-17 will be given coverage for the initial titrating doses as well. Jenkins A, Wang-Smith L, Marbury T, et al: Pharmacokinetics of treprostinil diolamine in subjects with end-stage renal disease on or off dialysis. Provider attests that the patient has achieved a clinically meaningful response while on Orkambi therapy to one of the following: a. Cystic fibrosis pulmonary guidelines: chronic medications for maintenance of lung function. Intra-articular hyaluronic acid in the treatment of osteoarthritis of the knee: A short-term study. Intra-articular hyaluronan injections in the treatment of osteoarthritis of the knee: A 190ulticente, double blind, placebo controlled 190ulticenter trial. Viscosupplementation with hylan for the treatment of osteoarthritis: Findings from clinical practice in Canada. Intra-articular hyaluronan injections for the treatment osteoarthritis of the knee: a randomized, double blind, placebo controlled study. Only for use by physicians experienced in antimetabolite therapy o Embryo-fetal toxicity: Exclude pregnancy before treatment. Trial of and inadequate response or intolerance to hydroxyurea, unless contraindicated or clinically significant adverse effects are experienced Reauthorization 1. Trial and inadequate response or intolerance to both of the following in the neoadjuvant/adjuvant, locally advanced or metastatic setting: a. Recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis. Management of postmenopausal osteoporosis: 2010 position statement of the North American Menopause Society. Any contraindication to therapy References Requests for continuing therapy that were approved by a previous Health Plan will be honored for at least 30 days upon receipt of documentation demonstrating that approval 1. One of the following: o T score at the lumbar spine, total hip, or femoral neck of less than 1. Usual dose: 60mg subcutaneously administered by a healthcare professional once every 6 months. Pediatric Vulvovaginal Disorders: A Diagnostic Approach and Review of the Literature. A comparison of once-daily and divided doses of modafinil in children with attention-deficit/hyperactivity disorder: a randomized, double-blind, and placebocontrolled study. Modafinil in children and adolescents with attention-deficit/hyperactivity disorder: a preliminary 8-week, open-label study. Efficacy and safety of modafinil film-coated tablets in children and adolescents with attention-deficit/hyperactivity disorder: results of a randomized, doubleblind, placebo-controlled, flexible-dose study. A randomized, double-blind, placebo-controlled study of modafinil filmcoated tablets in children and adolescents with attention-deficit/hyperactivity disorder. Requests for continuing therapy that were approved by a previous Health Plan will be honored for at least 30 days upon receipt of documentation demonstrating that approval 5. The efficacy and safety of armodafinil as treatment for adults with excessive sleepiness associated with narcolepsy. Adjunct armodafinil improves wakefulness and memory in obstructive sleep apnea/hypopnea syndrome. Randomized, double-blind, placebo-controlled crossover trial of modafinil in the treatment of residual excessive daytime sleepiness in the sleep/apnea/hypopnea syndrome. Efficacy and safety of modafinil (Provigil) for the treatment of fatigue in multiple sclerosis: a two centre phase 2 study. Modafinil film-coated tablets in children and adolescents with attentiondeficit/hyperactivity disorder: results of a randomized, double-blind, placebo-controlled, fixed-dose study followed by abrupt discontinuation. Randomized trial of modafinil as a treatment for the excessive daytime somnolence of narcolepsy. Treatment of hepatitis C in combination with peginterferon alfa-2b, interferon alpha-2a or interferon alfa-2b. Must be 5 years of age or older for capsule use or 3 years of age or older for solution use. Members who have failed previous therapy with Victrelis or Incivek-based regimens 6. Decompensated liver disease Coverage of ribavirin is not recommended in the following circumstances: Requests for continuing therapy that were approved by a previous Health Plan will be honored for at least 30 days upon receipt of documentation demonstrating that approval 1. An update on treatment of genotype 1 chronic hepatitis C virus infection: 2011 practice guideline by the American Association for the Study of Liver Diseases. Randomised, double-blind, placebo-controlled trial of interferon 2b with and without ribavirin for chronic hepatitis C. Long-term efficacy of ribavirin plus interferon alfa in the treatment of chronic hepatitis C. Randomised trial of interferon 2b plus ribavirin for 4 8 weeks or for 24 weeks versus interferon 2b plus placebo for 48 weeks for treatment of chronic infection with hepatitis C virus. Interferon alfa-2b alone or in combination with ribavirin as initial treatment for chronic hepatitis C. Peginterferon alfa-2b or alfa-2a with ribavirin for treatment of hepatitis C infection. Peginterferon-alpha2a and ribavirin combination therapy in chronic hepatitis C: a randomized study of treatment duration and ribavirin dose. Requests for continuing therapy that were approved by a previous Health Plan will be honored for at least 30 days upon receipt of documentation demonstrating that approval 37. Comparison of a Single Infusion of Zoledronic Acid with Risedronate for Pagets Disease. If this dose cannot be tolerated because of systemic effects, the infusion rate should be reduced to 0. Rich S, Calcium channel blockers and anticoagulants in the therapy of pulmonary hypertension. Continuous subcutaneous infusion of treprostinil, a prostacyclin analogue, in patients with pulmonary arterial hypertension. Efficacy and safety of treprostinil: an Epoprostenol analog for primary pulmonary hypertension. References Requests for continuing therapy that were approved by a previous Health Plan will be honored for at least 30 days upon receipt of documentation demonstrating that approval 1) Virginia Premier. Member has a record of 1 month trial of and inadequate response or intolerance to 2 of any of the following oral medications: Antidepressants. For use in children clinically diagnosed with hepatitis C with compensated liver disease previously untreated with alpha interferon; relapsed following alpha interferon therapy. Members who have failed previous therapy with Victrelis or Incivek-based regimens Requests for continuing therapy that were approved by a previous Health Plan will be honored for at least 30 days upon receipt of documentation demonstrating that approval 6. Decompensated liver disease Coverage of ribavirin is not recommended in the following circumstances: 1. Requests for continuing therapy that were approved by a previous Health Plan will be honored for at least 30 days upon receipt of documentation demonstrating that approval 15. Peginterferon alfa-2b plus ribavirin compared with interferon alfa-2b plus ribavirin for initial treatment of chronic hepatitis C: a randomised trial. Requests for continuing therapy that were approved by a previous Health Plan will be honored for at least 30 days upon receipt of documentation demonstrating that approval 36. High sustained virologic response rates in children with chronic hepatitis C receiving peginterferon alfa-2b plus ribavirin. American College of Rheumatology 2008 Recommendations for the Use of Nonbiological and Biologic Disease-Modifying Antirheumatic Drugs in Rheumatoid Arthritis. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Efficacy of B-cell-targeted therapy with rituximab in patients with rheumatoid arthritis. Safety and efficacy of additional courses of rituximab in patients with active rheumatoid arthritis. Requests for continuing therapy that were approved by a previous Health Plan will be honored for at least 30 days upon receipt of documentation demonstrating that approval 10. Dexamethasone plus rituximab yields higher sustained response rates than dexamethasone monotherapy in adults with primary immune thrombocytopenia. Report of the Quality Standards Subcommittee and T herapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and American Epilepsy Society. Steering Committee on Quality Improvement and Management, Subcommittee on Febrile Seizures. Febrile Seizures: Clinical proactive guideline for the long-term management of the child with simple febrile seizures. Vasopressin v(2) receptor blockade with tolvaptan versus fluid restriction in the treatment of hyponatremia. Requests for continuing therapy that were approved by a previous Health Plan will be honored for at least 30 days upon receipt of documentation demonstrating that approval 6. Gabapentin in the treatment of fibromyalgia: A randomized, double-blind, placebo-controlled, multicenter trial. Psychological interventions for major depression in primary care: a meta-analytic review of randomized controlled trials. Guideline for the management of fibromyalgia syndrome pain in adults and children. Comparative efficacy and acceptability of 12 newgeneration antidepressants: a multiple-treatments meta-analysis. Milnacipran for the treatment of fibromyalgia in adults: a 15-week, multicenter, randomized, double-blind, placebo-controlled, multiple-dose clinical trial. Comparative Effectiveness of SecondGeneration Antidepressants in the Pharmacologic Treatment of Adult Depression. Comparative benefits and harms of secondgeneration antidepressants: background paper for the American College of Physicians. Requests for continuing therapy that were approved by a previous Health Plan will be honored for at least 30 days upon receipt of documentation demonstrating that approval 11. A doubleblind comparison of the efficacy and safety of milnacipran and fluoxetine in depressed inpatients. Meta-analysis of major depressive disorder relapse and recurrence with second-generation antidepressants. A double-blind six months comparative study of milnacipran and clomipramine in major depressive disorder. Sechter D, Vandel P, Weiller E, Pezous N, Cabanac F, Tournoux A; study co-coordinators. A comparative study of milnacipran and paroxetine in outpatients with major depression. Double-blind study of the efficacy and safety of milnacipran and imipramine in elderly patients with major depressive episode. Mirtazapine versus other antidepressants in the acute-phase treatment of adults with major depression: systematic review and metaanalysis. Member has had a trial and failure, intolerance, or contraindication to at least one (1) of the following: a. Member has lost at least 4% or baseline bodyweight Approval Duration: 4 months Notes: Change in body weight with Saxenda should be evaluated every 16 weeks after initiation of medication. If the patient has not lost 4% of baseline body weight, Saxenda should be discontinued because it is unlikely that the patient will achieve and sustain clinically meaningful weight loss with continued treatment. If the patient cannot tolerate an increased dose during dose escalation, consider delaying dose escalation for one week. If the 3 mg daily dose is not tolerated, discontinue use as efficacy has not been established at lower doses. Tertiary hyperparathyroidism in post-kidney transplant patients not receiving dialysis All other indications are considered experimental/investigational and are not a covered benefit. Requests for continuing therapy that were approved by a previous Health Plan will be honored for at least 30 days upon receipt of documentation demonstrating that approval B.
Since sexual assaults frequently include nonsexual motives spasms muscle pain purchase 60ml rumalaya liniment otc, many perpetrators struggle to maintain an erection and never achieve orgasm muscle relaxant depression buy rumalaya liniment 60 ml without prescription. As a result muscle relaxant tinidazole rumalaya liniment 60 ml with mastercard, sexual assaults can continue for a lengthy period of time (Groth muscle relaxant withdrawal symptoms purchase cheap rumalaya liniment on line, 2001) without generating collectible physical evidence gastric spasms symptoms buy rumalaya liniment on line. When there is evidence muscle relaxant creams over the counter cheap 60 ml rumalaya liniment mastercard, anoscopy in cases of anal penetration and colposcopy are more likely to detect positive physical findings infantile spasms 9 months discount rumalaya liniment uk. Timing Considerations for the Evidence Collection Process: Conventional medical practice has promoted the notion that forensic evidence muscle relaxant walgreens buy generic rumalaya liniment 60 ml on line, in order to be useful and available, must be collected within a 72-hour period following a sexual assault. Recent evidence suggests that there are situations where evidence may be available beyond this time period (such as sperm might be found inside the cervix after 72 hours). Additionally, when the victim experienced significant trauma from the assault, has visible injuries, or has not washed themselves since the assault, evidence may be available, and visible trauma may be revealed using the culposcope and anoscope. As a result, some jurisdictions have extended their standard cutoff time beyond 72 hours. Evidence Integrity: In order to be admissible in a criminal prosecution, any evidence collected must be properly handled, using the jurisdictional policies for drying, packaging, labeling, and sealing of evidence, and then properly transferred from the exam site to the appropriate crime laboratory or storage facility. Storage procedures must always consider degradation, and care must be taken to ensure security and storage at proper temperature and environmental conditions. Finally, a demonstrable chain of custody must be maintained, in order to establish that the evidence collected was not in any way altered or changed from its original condition. Specific Steps in the Forensic Medical Examination Process: National 92 standards articulate eleven key steps of he process: 1. Initial Contact: Specific policies and procedures should guide initial contacts with victims, including recognizing and effectively managing medical trauma and crisis, establishing safety and support for the victim, and identifying options for care and treatment; 2. Triage & intake: Assessment, care and treatment of emergency medical and mental health trauma must precede any forensic medical examination. Ensure safety for the victim at all times and advise steps to be undertaken, always with informed consent. Documentation by health care personnel: All interventions, observations and treatments must be carefully documented, ensuring that it is reliable, objective, and complete. Medical Forensic History: this discussion should take place in a safe, confidential area, and be conducted with sensitivity and care. This history reviews the specifics of the sexual assault, and will guide subsequent medical examination, treatment and forensic evidence collection. Emerick and Dutton (1993) compared adolescent males polygraphed descriptions of their child sexual assault behaviors to investigative reports of the behaviors. Photography: Photographic evidence is an essential ingredient, but it can also be traumatizing and difficult for victims. The victim should understand the purpose of such photographs, be informed how they will be performed, and then, with permission, photographs should be taken of every site on the victims body where trauma related to the sexual assault is noted. Plans for follow-up photography should also be developed as necessary, because bruises and abrasions may be more apparent after several days. The needs of the victim should always guide the process, and each step should be reviewed with the victim, and informed consent secured. Appropriate, scientific procedures should be utilized, and all evidence should be collected, labeled, documented, and secured as specified, with particular attention to avoiding contamination or alteration. Drug Facilitated sexual assault: When it is suspected that a sexual assault has been drug facilitated, appropriate procedures should be established to inform the victim, and receive permission to conduct appropriate toxicology testing, whose results must be appropriately collected, labeled, documented and secured. Pregnancy risk evaluation and care: When the victim is a female, the probability of pregnancy must be discussed, a pregnancy test should be administered for all patients with reproductive capability (with permission), and appropriate treatment options, including reproductive health services, should be explored. Specific information concerning on-going necessary medical testing, and treatment should be provided, and referrals/appointments for followup medical/mental health care should be scheduled. Discharge planning should also include consideration of planning for safety and well-being, physical comfort needs, information needs, the investigative process, advocacy and counseling options, and law enforcement and advocacy follow-up contact procedures. Examiner Court appearances: the ability of the examiner to provide competent testimony requires sufficient education, prompt notification, sufficient pre-trial preparation, and appropriate feed-back upon completion of testimony to improve future effectiveness. Clinical Practice Content Recommendations: All healthcare practitioners should employ the best practice guidelines for the interventions provided 12, 98 by the Centers for Disease Control and Prevention. The team typically includes health care personnel, victim advocates, law enforcement officers, prosecutors, and forensic lab personnel (typically available to consult with examiners, law enforcement, or prosecutors, but not actively involved at this stage). A number of correctional agencies, notably Idaho, Kansas, Oregon and Utah, have adopted this model to provide appropriate, victim-sensitive service to victims, and such 99 endeavors are worthy of review. Ifvaginaldisch arge,malodor,oritch ingisevident,th ewetmountalso sh ouldbeexamined forevidenceofB V (Bacterialvaginosis)andcandidaisis. F ollow-updosesofvaccinesh ouldbeadministered1-2 and4-6 month safterth efirstdose. Conclusion: Effectively managing the medical consequences of inmate sexual assault requires that correctional agencies and healthcare providers work collaboratively to manage the many and complex issues faced by victims. Positive healthcare interventions can help to mediate and effectively treat the many symptoms of inmate sexual violence. By utilizing empirical data, fostering state-of-the-art interventions, establishing clear, concise protocols, and increasing staff training and communication, it may be possible to effectively respond to the crisis of inmate sexual violence. How to screen your patients for sexual assault: A Guide for Health Care Professionals. Addressing Sexual Violence in Prisons: A National Snapshot of Approaches and Highlights of Innovative Strategies. Sexually transmitted diseases in abused children and adult victims of rape: A review of selected literature. Confronting Americas most ignored crime problem: the Prison Rape Elimination Act of 2003. The utility of anoscopy and colposcopy in the evaluation of male sexual assault victims. The effect of polygraphy on the self-report of adolescent sex offenders: Implications for risk assessment. Violence against women: Physical and mental health effects, Part 1: Research findings. Raperelated pregnancy: Estimates and descriptive characteristics from a national sample of women. Somatic symptoms, social support, and treatment seeking among sexual assault victims. Relation of criminal victimization to health perceptions among women medical patients. Prison madness: the mental health crisis behind bars and what we must Do About It. An unanswered health disparity: Tuberculosis among correctional inmates, 1993 through 2003. Full report of the prevalence, incidence, and consequences of violence against women. A national protocol for sexual assault medical forensic examinations: Adults/adolescents. Best correctional practices require administrators to assist victims of prisoner sexual 96 violence. Victims of sexual violence undergo a destructive, catastrophic, life-changing event and are, as a result, likely to experience physical, emotional, cognitive, psychological, social and sexual 26,p. Sexual assault is a situational crisis that precipitates a variable degree of trauma in its victims. The psychological impact often impedes the victims use of their normal problem solving 41 resources. Correctional agencies are challenged to manage the immediate, short-term and long term effects of sexual victimization. Concrete, systematic interventions can help mitigate the life crisis and trauma that results from inmate sexual violence. An effective system of intervention for victims of sexual assault in correctional institutions will encourage reporting, keep victims safe, address victims mental health trauma, involve community-based sexual assault providers, increase participation in criminal prosecution, and assist in transition to the community. Many of these issues were identified in the Urban Institute Report, Addressing Sexual 129 Violence in Prisons. When implementing services, correctional officials should consider the importance of choice and active participation by the inmate victim, when this is possible and appropriate. Judith Herman from the Harvard Medical Center notes that in rapethe attackdemonstrate[s] contempt for the victims autonomy and dignity. In the community, victims may be unwilling to report out of fear, guilt, shame, and feeling that they 19,23,35, 41,54 will not be believed. In correctional settings, victims may be reluctant to notify authorities for many of the same reasons, and for reasons that relate to specific dynamics of the environment. If an 26,27,39,68 inmate reports being sexually victimized, he or she may be placed in a very difficult situation: staff 43,45 may respond poorly or blame the victim; a victim may be placed in protective custody, segregation, or 24 106 35,44 transferred; or a victim may be labeled as a homo or punk or snitch. In addition, there is a perception that 44 inmates are not real victims, that most sexual behavior in jails and prisons is consensual, or that 37,100,110 victims, in fact, deserve, their fate. When victims fail to report victimization, they may be subject to on-going trauma, and, they may not receive much needed therapeutic treatment [medical & mental 33,39,41,80,84,111, 112,113,128 health]. When inmates believe that their reports will be taken seriously, that they will be provided with adequate protection and safety, when substantive medical and mental health interventions are available and kept confidential, and when discipline and prosecution are used 40 appropriately, reporting will be improved. Administrators can invest in multiple, over-lapping, safe and confidential reporting mechanisms that inmates can use. Innovative approaches have been implemented 129 in a number of jurisdictions including: Availability and access to no-cost, confidential hotlines to agency investigators, external law enforcement agencies and offices of inspector general; Posters, brochures and other public acknowledgements that identify reporting options and a clear policy that sexual abuse will not be tolerated, reinforced by inmate education and orientation, in clear, understandable language 264 Regular, periodic case reviews with inmates whether by classification, case managers or medical staff, which includes routine questions regarding how safe the inmate feels and whether he/she has ever felt sexually threatened Exit interviews that include questions regarding safety with inmates prior to release, including the use of civilian staff or staff external to the agency Safe mechanisms for victims to file confidential memoranda and/or grievances Ability to confidentially consult with correctional administrators, medical, and mental health staff Access to community rape crisis staff and/or community advocacy staff. Since many victims do not report the crime, there are a number of behavioral indicators that might prompt correctional staff to consider whether an inmate has been the victim of prisoner sexual violence. These include: Asking for a room or roommate change Changes in behavior such as acting out to get into segregation Staying in their room Not showering Refusing to participate in an activity that they formerly participated in Substance abuse Suicidal ideation or attempts Self injurious behavior Buying commissary and eating in their room Inmate debt or family transfers to other accounts If staff suspect that an inmate has been victimized, the inmate should be interviewed in an area that avoids raising the suspicions of the inmate population and provides privacy. Correctional agencies, both juvenile and adult, have the obligation to create a safe environment for inmates to report sexual victimization, and to insure that inmates will be kept safe and receive the necessary treatment. Victims must know that they will be kept separate from their perpetrator(s) (whether inmate or staff), and that they will not be subjected to further harm or injury. Additionally, victims must be placed in housing that will ensure no on-going retribution or continued 26,27,32,35,41,77,112,113,128 victimization. Correctional agencies are often faced with limited choices (returning a 129 victim to general population, transfer to a protected custody setting or to another facility), and they may inadvertently re-victimize an inmate by placement in protective custody for his/her own wellbeing. Because the inmate now experiences significant loss of freedom, ability to access programs and services, 32,39,41,129 and loss of personal belongings, job and other grounding events, the effects of victimization can be increased dramatically. Correctional officials should not automatically default to protective custody for the victim, but should examine the options that exist. When possible, the perpetrator (not victim) should be moved to administrative segregation or outside the institutions. Victims may be placed in cells in closer proximity/scrutiny to correctional staff or in hospital and other more closely supervised units. If it is necessary to move the victim into a more protective environment, care should be taken to avoid disruption of daily life activities, to minimize the deprivations of programs and services available in general population, and to return the victim to a less restrictive environment when appropriate. The goals should be to avoid labeling the victim, which can be catastrophic, and to ensure (especially over the long-term) appropriate classification, 32,39,41,129 so that victim and perpetrator will not be re-housed in the same unit or facility in the future. In addition, if prosecution is undertaken, care should be taken to seek changes of venue if appropriate. Because correctional environments also have extensive informal networks, consideration of the social consequences especially with other inmates and staff should be considered. The first priority is to treat the imminent physical and life-threatening injuries sustained by the victim, while minimizing disruption to 16,17,18,19,41 forensic evidence collection. Advising the victim of what is to be expected and what will be occurring during this process can minimize the inevitable trauma. At all times, victims should be treated with dignity, respect and afforded privacy and confidentiality during these difficult interventions. Care should be taken to ensure continuity of care throughout incarceration 26,27,35,39,41 (including transfer to other facilities) and upon transition into the community. Each individual responds to the crisis of sexual victimization in a unique and individual way. It is normal for victims to initially withhold details that they find most embarrassing, shameful, or that call their credibility into question. When these additional details are later exposed or reported, some staff may question the legitimacy of the sexual assault report, however, it is important to remember that withholding details is a typical victim behavior whether the sexual assault took place in the community or a correctional institution. The degree and severity of the resultant trauma also varies from victim to victim. Recovery, in general, is a function of the (1) victims pre-victimization characteristics, (2) victims post-victimization 73,74,81,85 abilities to cope and (3) factors related to the criminal event. Stages are non-linear, and victims can progress and vacillate through various stages. They may display a range of feelings, including crying, sobbing, smiling, restlessness, tenseness, & joking. They may appear distraught or anxious and may even express rage or hostility against the staff attempting to care for them. They present a flat affect, quiet, reserved and have difficulties expressing themselves. Immediate effects first weeks: Physical/Somatic manifestations include: physical trauma (soreness/bruising), skeletal muscle tension (headaches, fatigue), gastrointestinal irritability (stomach aches, nausea, appetite & bowel changes), and genitourinary disturbances (oral/anal burning, itching; gynecological problems, pain, bleeding). Emotional reactions include: shock, numbness, embarrassment, guilt, powerlessness, loss of trust, humiliation, fear of physical violence and death, anxiety, anger, guilt, disbelief, revenge & wish for revenge, shame, depression, denial, re-triggering of trauma both prior and current, disorientation, self-blame, self-hatred, self-doubt, and in some cases self-mutilation and self injury. Denial frequently masks underlying problems as victims make an effort to re-establish routines and control. Symptoms may include, but are not limited to: changes in lifestyle (changes in friends, family, contact, job, appearance, routines), somatization (physical ailments, appetite disturbances, vomiting, eating, insomnia, recurrent nightmares, vivid dreams), phobias (preoccupation w. During this stage the sexual assault is no longer the central focus in the victims life, but is part of ones life experience. While the victim will never forget the assault, the pain and memories associated with it are lessening. S/he has accepted the rape as a part of her/his life experience and is choosing to move on from there. Compound Reaction: Characterized by all of the defining characteristics of rape trauma and other symptoms (especially if victim experienced previous sexual/physical abuse) and may include: severe depression; suicide attempts; psychosomatic illnesses & complaints; increased sexual activity/promiscuity; increased drug and/or alcohol abuse; overeating; psychotic behavior. Silent Reaction may replace rape trauma or compound reaction, and may include: abrupt changes in usual sexual relationships; increase in nightmares; increasing anxiety during interview(s) about rape incident; marked change in sexual behavior; avoidance of relationships; denial of rape/refusal to discuss it. A key and important principle should guide all interventions: the differing responses to traumatic 120 events and crisis are normal responses to abnormal circumstances. Staff are in a critical position to maximize healing and coping in victims, and they should endeavor to validate the victims feelings 72,90,120 120 and normalize the situation. Treatment that is undertaken should represent a partnership between the victim, treating clinicians and the correctional agency. All staff should become familiar, through on-going staff training, with the grave problems a victim may experience and refer inmates to medical and mental health 41,116,117 114 staff. Staff should especially avoid the second injury, the perceived rejection, indifference, or lack of support by staff/agencies, or the projections (conscious/unconscious) of blame on the victim, by treating each victim with dignity, respect and human compassion from the beginning whether or not officers suspect the report is valid. Visible skepticism on the part of officers may encourage an inmate to abandon reporting and may result in a loss of critical safety information regarding the facility. Genuine concern and appropriate empathy from staff can have a reassuring effect upon the victim. Immediate, Short-Term & Long-Term Consequences and Intervention Strategies Stage Major Issues Key Intervention Strategies Crisis Crisis Services: Immediately, victims experience a lack of control Ensure safety for victim physical pain & suffering Separate victim from perpetrator threat of further harm or death Provide necessary medical care and forensic evaluation Victims often articulate shock, Evaluate suicide risk disbelief, panic & fright, fear Negotiate psychological assistance Victims may employ host of coping and on-going mental health care strategies w. The disorder consists of: Intrusive symptoms (flashbacks, nightmares, reliving the experience, intense psychological or physiological distress at exposure to cues associated with the traumatic event); Constrictive symptoms (emotional numbing, isolation, avoiding thoughts or activities associated with trauma, fear of leaving room, or participating in activities or relationships which are similar to the trauma, sense of foreshortened future); Hyperarousal symptoms (insomnia, irritability or outburst of anger, difficulty concentrating, hypervigilance, exaggerated startle reactions). The symptoms cause distress or impairment in social, occupational or other areas of functioning. Symptoms may be acute (less than 3 months), chronic (3 months or more), or delayed (6 months after stressor). Effectively managing the mental health trauma requires focus on three major mental health issues: Suicide; Posttraumatic Stress Disorder/Rape Trauma Syndrome; and Other Psychiatric Disorders and Coping. Contemplating and/or attempting 67 suicide is far more likely among victims of sexual violence.
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