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Kristine S. Schonder, PharmD

• Assistant Professor, Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania

https://www.pharmacy.pitt.edu/directory/profile.php?profile=113

There is an increased incidence of falls with advancing this can be managed by reducing the dose or age erectile dysfunction medication nz order 80 mg super levitra mastercard. Antiemetics and neuroleptics Parkinsonian syndrome impotence at age 30 purchase cheap super levitra online, confusional state erectile dysfunction shake recipe buy super levitra 80mg low price, postural hypotension erectile dysfunction caused by anabolic steroids purchase super levitra 80 mg with amex, tardive dyskinesia erectile dysfunction cures discount generic super levitra uk, drowsiness erectile dysfunction in a young male generic super levitra 80mg visa, susceptibility to hypothermia 3. Anticholinergics and antidepressants Confusional states, urinary retention, constipation, dry mouth. Some Drugs to be Avoided/Used with Caution in Disorders in the Elderly Disorder Drugs to be avoided/used with caution 1. Hypertension Use vasodilators with caution as it can precipitate postural hypotension and stroke. Sublingual nitroglycerin to be administered in the lying posture as it may precipitate postural hypotension and falls if administered in the sitting or standing posture. Mural thrombus Oral anticoagulants (warfarin) to be used with caution as there may be increased activity due to reduced plasma binding of the drug. Prolonged use of heparin may exacerbate pre-existing osteoporosis and produce pathological fractures. Theophylline to be used with caution as impaired hepatic oxidation/hydroxylation can increase plasma level of the drug to toxic levels. Prolonged administration of steroids to be avoided as it may result in exacerbation of pre-existing osteoporosis and electrolyte imbalance (hypokalaemia). Diarrhoea Fluid and electrolyte loss should be carefully monitored and their replacement must be meticulous. Hypovolaemia and haemoconcentration can result in stroke, peripheral vascular occlusion and gangrene. Avoid use of antispasmodics or antimotility agents as they may produce paralytic ileus 9. Constipation Avoid prolonged use of laxatives as they may produce hypokalaemia 10. Hyperthyroidism/senile tremors Initiate propranolol therapy with caution as its serum level may be increased due to decreased first pass metabolism through the liver. Psychiatric disorders Antipsychotic drugs must be used with caution as they may cause falls and confusional states. Skin over pressure points should be inspected decrease in total body water and increase in body frequently. Drug therapy in the elderly should be employed only ed and fat soluble drugs have longer half-lives). Once pharmacotherapy has been decided upon, the so there is decrease in protein binding of some drug should be started with the minimal optimal drugs. The number of drugs administered should be as few Drugs Cleared by the Kidney which should as possible. The dosage schedule of the drugs administered should be such that maximal patient compliance is 1. Antibiotics Gentamicin, streptomycin, attained as decreased compliance due to memory kanamycin. Chapter 13 Substance Abuse 770 Manual of Practical Medicine Alcohol Metabolism of Alcohol Alcohol is metabolised by Alcoholic Equivalents a. Risk Factors for Alcoholic Liver Disease Consumption of alcohol results in gain of empty 1. Continuous alcohol drinking is more dangerous than intermittent Mechanism of Liver Injury consumption. Acetaldehyde binds with phospholipids, amino Women develop higher blood ethanol values following acid residues, and sulphydryl groups and thus a standard dose intake and it progresses from alcoholic becomes reactive and toxic. It is membranes by depolymerising proteins and because the alcohol dehydrogenase, from the gastric altering surface antigens. In the more severely affected conditions, fatty change is diffuse (usually fat accumulates in zones 3 and 2). Liver cell damage (typical ballooning degener passive diffusion from the stomach and the duodenum. Substance Abuse 771 the prominent features of alcohol hepatitis is the Lab Features Mallory body or Mallory hyaline (also seen in a. The formation of the nodules is often slow, Hepatic Cirrhosis because of a presumed inhibitory effect of alcohol on hepatic regeneration. The patients are usually asymptomatic, the diagnosis being made when an enlarged, smooth, firm liver is present. The conventional function and predominantly affects frontal cortical anticonvulsants are less effective. Withdrawal Syndrome illness, and later progresses rapidly to fits, rigidity, this syndrome is present in chronic alcoholism (regular paralysis, coma and death. Cerebrovascular Disease Consumption of large quantity of alcohol is the most common cause of stroke in the young. The increased risk of stroke is thought to be due to factors like increased viscosity of blood, coagulation defects and dysrhythmias. The possible consequences of high alcohol consumption are intracerebral haemor rhage, cerebral infarction, or subarachnoid haemor rhage. Alcoholics are also prone to develop subdural haematoma as a consequence to head injury while in an intoxicated state. Alcoholic Cerebellar Degeneration It is due to degeneration of cerebellar cortex (Purkinje cells) and superior and anterior part of the vermis. The clinical features are ataxia, progressive unsteadiness of gait with more involvement of the lower limbs than the upper limbs. Central Pontine Myelinosis haemorrhages in the upper brainstem, hypothalamus, thalamus adjacent to third ventricle and the mamillary It is a rare disorder occurring in alcoholics and a number bodies. Peripheral Neuropathy Pregnancy and Alcohol It is due to predominant axonal neuropathy of the dying back type, affecting the somatic and autonomic nervous Foetal Alcohol Syndrome system. Alcohol consumption in the later stage of pregnancy results in intellectual deficit, 10. Saturday Night Palsy auditory and visual deficits, and hyperkinetic this is a condition whereby there is compression trauma syndromes in the offspring. Alcoholic Myopathy Gastrointestinal It is characterised by severe muscle pain and tender Oesophagus ness, myoglobinuria and renal damage with hyper kalaemia. Mallory-Weiss syndrome: It is characterised by longi tudinal tear in the mucosa at gastro-oesophageal Tobacco Alcohol Amblyopia junction in chronic heavy drinkers during violent It is an uncommon complication of alcoholics. The clinical features are epigastric pain, nausea, and (Confabulation Psychosis) vomiting. It is characterised by a triad of ophthalmoplegia (nystag Pancreas mus and impaired ocular abduction), cerebellar ataxia, and confusional state. It interferes with absorption of B-vitamins and pathological changes are hyperemia with multiple small nutrients. It also produces haemorrhagic lesions of the in ovarian size and absence of corpora lutea) and duodenal villi. Bone Haematology Alcohol intake manifests as fracture (due to alteration of calcium metabolism) and osteonecrosis of femoral It manifests as a reversible acute and chronic disorder head. Platelets: Mild thrombocytopenia, hypersplenism (cirrhosis), decrease in platelet aggregation and 1. Cardiovascular System It reduces the myocardial contractility and causes peripheral vasodilatation. The development of atrial or ventricular arrhythmias occurs after a binge in individuals showing no other Alcohol and Lymphatic System evidence of heart disease. Sedatives: the sedative effects of alcohol are increased Modest alcohol dose (blood alcohol level is 100 mg/dl by concurrent intake of sedatives, hypnotic, or opioid or even less) intake manifests as increased sexual drive, drugs. There is gross impairment of psychomotor decrease in erectile capacity and testicular atrophy, function. Monoamine oxidase inhibitors: Some alcoholic drinks anorexia and nausea contain tyramine and so there may be a risk of It occurs within a few hours after cessation of developing severe hypertension in patients taking drinking and resolve within 48 hours. Multivitamins containing folic acid and balanced eliminate alcohol slowly and so the effect of alcohol diet is prolonged. When alcohol Anticonvulsants are not indicated since this is self is also consumed along with any one of these drugs, limited. Thiamine should be given prior to glucose the level of acetaldehyde rises markedly leading to while correcting hypoglycaemia. Consider other facial flushing, tachycardia, hypotension, dyspnoea, causes for seizure. Warfarin: Acute alcohol intoxication potentiates the hallucinations, agitation, confusion, and autonomic hypoprothrombinaemic effect of warfarin leading hyperactivity (fever, tachycardia, and diaphoresis) to bleeding tendencies. Co-carcinogens like catechol enhance are three major risk factors for coronary heart disease the carcinogenecity. Smokers have impaired exercise performance, impaired Smokers have an increased perioperative mortality immune system compared to non-smokers. Inhibition of nocturnal acid secretion by H2 blockers is also prevented Oral cavity Pancreas Larynx Kidney by smoking. Lung Urinary bladder Oesophagus Uterine cervix Smoking and Depression Stomach Myelocytic leukaemia Prevalence of smoking is increased in those who have a major depressive disorder. Smoking and Pregnancy Smoking delays conception and smoking during Pack Year pregnancy affects the foetus. This is due to impaired the risk of developing lung cancer is 40 times more uteroplacental circulation. Spontaneous abortion, foetal death, neonatal death and sudden infant death syndromes are also common. Smoking and Respiratory Disease the long term physical growth and intellectual develop ment of the child is also affected. Passive Smoking Prolonged cigarette smoking impairs ciliary move ment, inhibits function of alveolar macrophages and Since side stream smoke is diluted in a large volume of leads to hypertrophy and hyperplasia of mucus secreting air, smoke exposure from involuntary inhalation is less glands. The Passive smoking is one of the causes for lung cancer inhaled cigarette smoke increases airway resistance due in non-smokers. Parental smoking is a cause for middle to vagally mediated smooth muscle constriction by way ear effusions, acute or chronic respiratory illness and of stimulating submucosal irritant receptors. Passive smoking may also cause Abnormalities in pulmonary function tests, (mea coronary heart disease. Smoking and Drugs There is increase in incidence of respiratory infections and deaths due to pneumonia and influenza. Post Tobacco smoke constituents induce hepatic microsomal operative respiratory complications, spontaneous enzyme systems which are important in the metabolism pneumothorax are also common. Chronic pharyngitis, of drugs like propranolol, theophylline and chronic laryngitis and chronic bronchitis occur more propoxyphene and hence increase in dose in smokers is frequently in smokers. Chlorpromazine Decreased serum concentration Clomipramine Decreased serum concentration Pharmacotherapy Clozapine Decreased serum concentration 1. Nicotine containing chewing gum 2 or 4 mg chewed Haloperidol Decreased serum concentration over 20-30 minutes, repeated upto 60 mg/day. Transdermal nicotine patch; started as high dose vasoconstriction patch, 21 mg/day for 6 weeks followed by inter Theophylline Faster metabolic clearance mediate dose patch, 14 mg/day for 2-4 weeks followed by low dose patch, 7mg/day for 2-4 weeks.

Diseases

• Charcot Marie Tooth disease type 1B
• Superior mesenteric artery syndrome
• Spondylometaphyseal dysplasia, Sedaghatian type
• Familial non-immune hyperthyroidism
• Kennedy disease
• Alpha-L-iduronidase deficiency
• Hypert Hyperv
• Orofaciodigital syndrome Thurston type

This is followed by anovulation erectile dysfunction treatment new zealand order super levitra with paypal, markedly reduced oestrogen levels and amenorrhoea best erectile dysfunction pills over the counter generic super levitra 80 mg without prescription, inducing a postmenopausal state and regres sion of endometrial deposits erectile dysfunction young causes purchase 80mg super levitra fast delivery. As these need daily dosing they are not commonly prescribed erectile dysfunction treatment new jersey order super levitra in india, as psychologically the patient is constantly reminded of the disease erectile dysfunction cream buy super levitra 80mg lowest price. I Goserelin erectile dysfunction wife order cheapest super levitra and super levitra, leuprorelin and triptorelin are monthly depot injection preparations which are more convenient. GnRh analogue treatment is only licensed for six months and only a single course of treatment is recommended by the manufacturers. This is a combination of one or more hormones with GnRh analogues to minimise or eliminate hypo oestrogenic adverse effects such as bone loss and hot ushes. Other adverse effects of GnRh analogues include insomnia, reduced libido, vaginal dryness and headaches. With buserelin or naferelin, if a nasal decongestant is 168 Pharmacy Case Studies required, it should not be administered before or for at least 30 minutes after GnRh analogue use. With naferelin, sneezing during or immediately after dosing may impair absorption. I Eclampsia is de ned as the occurrence of one or more convulsions superimposed on pre-eclampsia. I Pre-eclampsia is pregnancy-induced hypertension in association with proteinuria (>0. I Severe pre-eclampsia is severe hypertension (diastolic blood pressure >110 mmHg on two occasions or systolic blood pressure >170 mmHg on two occasions) together with signi cant proteinuria (at least 1 g/L). In pre-eclampsia, a rise in uric acid correlates with poorer outcome for both mother and baby. If creatinine is found to be elevated early in the disease process, underlying renal disease should be suspected. Falling platelet count is associated with worsening disease and is itself a risk to the mother. If count is less than 100 106/L there may be associated coagulation abnormalities, and delivery should be considered. Antihypertensive treatment should be started if systolic blood pressure >160 mmHg or diastolic >110 mmHg. The drug with which there is most experience in the treatment of hypertension in pregnancy is methyldopa. Other drugs with which there is experience include prazosin, hydralazine and nifedipine. Administration of certain beta-blockers, such as atenolol, during pregnancy may result in an increase in fetal growth retardation, although labetalol may be reasonably safe. Diuretics are no longer used in pregnancy and are usually reserved for women with renal or cardiac problems. The Magpie Study demonstrated that administration of magnesium sulphate to women with pre-eclampsia reduces the risk of an eclamptic seizure. If given, it should be continued for 24 hours following delivery or 24 hours after the last dose, whichever is the later. I Regular assessment of urine output, maternal re exes, respiratory rate and oxygen saturation is important. I Magnesium toxicity can be assessed clinically as it causes loss of deep tendon re exes and respiratory depression. I Calcium gluconate 1 g (10 mL) is given by slow intravenous injection (over 10 min) for magnesium toxicity. Fluid restriction is advisable to reduce the risk of uid overload in the intra partum and postpartum periods. There is no bene t of uid expansion; it may increase the risk of caesarean section. The regimen of uid restriction should be maintained until there is a postpartum diuresis as oliguria is common with severe pre eclampsia. I She should be carefully reviewed before discharge as there is a risk of late seizures. I If there is persistent hypertension and proteinuria at six weeks she may need further investigation for renal disease. I Currently there is insuf cient evidence to recommend any particular antihypertensive. Good practice is to avoid methyldopa postnatally due to its adverse side-effect pro le, especially depression. I In breastfeeding women, labetalol, atenolol, nifedipine and enalapril are in use either singly or in combination. At this point you also notice that his right index and middle ngers as well as his teeth are stained yellow. What alternative formulations could you suggest in order to facilitate medication compliance in this case General references Joint Formulary Committee (2008) British National Formulary 55. At the time of admission, her laboratory results from blood analysis were as follows: Full blood count Hb 8. She refuses to have a central line placed so will be receiving her chemotherapy through a peripheral intravenous catheter. Questions 1 What are the typical signs and symptoms of bowel cancer that should alert a healthcare professional to refer to a specialist Taylor I, Garcia-Aguilar J and Goldberg S (eds) (1999) Chapter 2: Clinical presentation. She presents with a one-week history of drowsi ness, nausea and vomiting, loss of appetite and abdominal pain. The consultant oncologist initially reviewed her in his outpatient clinic where a blood sample was taken and she was further examined. Her height and weight were also recorded: height 162 cm and weight 79 kg (body surface area 1. She was initially treated with surgery (wide local excision and axillary clearance), adjuvant anthracycline-based chemotherapy and radiotherapy. General references Summary of Product Characteristics (2008a) Herceptin injection. Summary of Product Characteristics (2008b) Taxotere injection, Available at emc. South West London, Surrey, West Sussex and Hampshire and Sussex Cancer Networks and Northern Ireland Palliative Medicine Group. He presents with a two-week history of malaise and lethargy, dyspnoea, right testicular swelling and dif culty in passing urine. An urgent blood sample is taken and the results show the following: Full blood count Hb 16. An orchidectomy was arranged and histology con rmed a diagnosis of non-seminomatous germ cell tumour. He suffered only occasional bouts of slight nausea and was already nding it easier to breathe and pass urine. He was discharged home that evening with the following medication: I ondansetron 8 mg p. On discussion he reports suffering from severe nausea and two or three episodes of vomiting over a 4-day period just after being discharged following his rst cycle. Further questioning also reveals considerable non-compliance with his prescribed antiemetic regimen. How would you try to ensure patient concordance with the management of his nausea and vomiting General reference Summerhayes M and Daniels S (2003) Appendix 2: Dosage adjustment for cytotoxics in renal impairment. Scenario Every Monday in your oncology outpatient department, you run a pharmacist/ nurse-led oral capecitabine clinic, where patients are referred to you by oncol ogists for pretreatment counselling, drug history-taking and supplementary chemotherapy prescribing (under set clinical management plans) for the adjuvant treatment of colon cancer or treatment of metastatic colorectal cancer. After undergoing a surgical resection of her tumour (right hemicolec tomy) she received adjuvant folinic acid/5 uorouracil chemotherapy for six months. Further investigation had con rmed a recurrence of her colon cancer, with metastatic spread to the lungs and liver. Questions 1 What are the treatment options for the rst-line therapy of metastatic colorectal cancer You then discuss what medication she is currently taking, which are as follows: I co-amilofruse 5/40 one tablet p. You explain to her that her consultant oncologist has decided that she should commence single-agent oral capecitabine chemotherapy. You also notice that she has brought back empty boxes of capecitabine from her rst cycle, indicating that she nished her treatment as prescribed. General references Allwood M, Stanley A and Wright P (eds) (2002) the Cytotoxics Handbook. Solimondo D, Bressler L, Kintzel P and Geraci M (2007) Drug Information Handbook for Oncology. Summerhayes M and Daniels S (2003) Practical Chemotherapy: A Multidisciplinary Guide. An individual who smokes one packet of cigarettes daily has a 20-fold increased risk of lung cancer compared with a non-smoker. Smoking cessation decreases the risk of lung cancer, but a signi cant decrease in risk does not occur until approximately 5 years after stopping. Numerous clinical trials have proven this bene t, and the use of both drugs together is now accepted practice. This can occur in up to 10% of patients and is generally mild to moderate in nature. This information could be supported by checking the pharmacy electronic computer records for his drug history. Ondansetron also commonly causes headache that is typically of a mild to mod erate nature and may be treated with simple analgesics such as paracetamol. Other unwanted effects are generally mild and transient and include light headedness, abdominal discomfort, hiccups, fatigue and asymptomatic rises in liver transaminases. Malignant diseases case studies 187 Dexamethasone may cause side-effects typical of corticosteroid adminis tration. Many of its more serious adverse effects occur on long-term treatment, while other generally less serious effects may become apparent during short term treatment periods. Ranitidine is generally well tolerated but may occasionally cause diarrhoea and other gastrointestinal disturbances, altered liver function tests, headache, dizziness, rash and tiredness. Other rare side-effects include acute pancreatitis, bradycardia, atrioventricular block, confusion, depression and hallucinations, particularly in the very ill or elderly. Cancer patients often have mechanical obstructions caused by tumours, particularly of the head and neck, oesophagus or lung. It is therefore important for the pharmacist to advise on and provide alter native formulations of medications to facilitate patient compliance. Speci cally: I Ondansetron is available in a liquid form (4 mg/5 mL syrup), oral lyophilisates (tablets which are placed on the tongue, allowed to disperse and then swallowed) or suppositories (although these can cause rectal irritation). I Ranitidine is available either in a liquid form (75 mg/5 mL syrup) or as effervescent tablets that may be dissolved in water.

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His general physical examination findings are normal erectile dysfunction meds list cheap super levitra 80mg on line, other than common stigmata of trisomy 21 erectile dysfunction treatment in kenya buy 80mg super levitra. His neurologic examination shows low tone in his upper extremities and increased tone in his lower extremities erectile dysfunction causes medications buy 80 mg super levitra fast delivery. His lower extremity increased tone and hyperreflexia are unexpected erectile dysfunction due to diabetes icd 9 super levitra 80 mg without prescription, and suggest a spinal cord lesion such as cervical cord compression due to atlantoaxial instability erectile dysfunction doctor tampa discount generic super levitra canada. Increased tone in his legs is making it difficult for him to participate in his usual physical activities erectile dysfunction treatment without side effects purchase genuine super levitra online. Atlantoaxial instability occurs when there is increased mobility between vertebrae C1 (atlas) and C2 (axis). Although patients with atlantoaxial instability can be asymptomatic, there is a risk of spinal cord compression. Symptoms of spinal cord compression include increased tone or spasticity in the limbs, hyperreflexia, bowel or bladder incontinence, torticollis, or neck pain. These symptoms can have a slow onset, as in the boy in the vignette, or they can present abruptly, especially if there is sudden neck hyperextension or flexion as can happen in active sports, falls, or during a procedure such as intubation. If acute spinal cord compression is suspected, the patient should be referred immediately to the emergency department for neurosurgical evaluation. Anemia, hypothyroidism, leukemia, and obstructive sleep apnea can all cause fatigue and decreased exercise tolerance, but none of these cause spasticity or hyperreflexia. He had frequent episodes of acute otitis media as an infant and had myringotomy tubes placed at age 2 years, after which he had only occasional ear infections. Since an episode of acute otitis media 3 months ago, he has had frequent recurrences of purulent ear drainage from his left ear, which improved when treated with topical fluoroquinolone/glucocorticoid drops. Screening shows a mild decrease in hearing in the left ear, with normal hearing in the right ear. Persistent purulent otorrhea for more than 2 weeks despite treatment is an indication for referral to otolaryngology. Thus, the most appropriate next step in management would be referral to an otolaryngologist, who can thoroughly clean and examine the ear under the operating microscope. The epithelial cells then produce and deposit keratin and other debris inside the cyst, causing the lesion to grow. In developed nations, lethal complications of cholesteatoma are very rare, but permanent hearing loss may occur in untreated cases. Purulent otorrhea in children is defined as acute (< 6 weeks duration) or chronic (6 weeks duration). The most common organisms isolated are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Other frequent causes of acute purulent otorrhea include otitis externa, ventilation tube placement complication, cholesteatoma, and foreign body. Chronic suppurative otitis media is the most common cause of chronic purulent otorrhea, with biofilm-producing Staphylococcus aureus and Pseudomonas aeruginosa being the most commonly isolated organisms. Neoplasm, histiocytosis, and infection related to immunodeficiency states are much rarer causes of purulent otorrhea. Debate exists regarding the impact of water exposure on the development of otorrhea. Generally, ear plug use and strict water avoidance for children with ventilation tubes are no longer recommended. However, in children older than 6 years, otorrhea occurs most often during the summer swimming season. Thus some practitioners still recommend that precautions be taken for children in this age group when swimming. Given the duration and recurrent nature of his symptoms, water avoidance is unlikely to be curative for the boy in the vignette. Although treatment with amoxicillin and an ototopical antibiotic would be appropriate for a child with acute otitis media with perforation, it is not appropriate for a child with chronic symptoms such as the boy in the vignette. The role of allergy in otitis media with effusion and chronic suppurative otitis media remains controversial, with inadequate data on which to base a recommendation for referral to allergy/immunology at this time. Failure to resolve purulent otorrhea despite adequate treatment is an indication to search for an underlying condition. It is not appropriate to administer repeated courses of fluoroquinolone/glucocorticosteroid drops. Cost effectiveness of treatment of acute otorrhea in children with tympanostomy tubes. The baby was born by normal spontaneous vaginal delivery with no pregnancy or delivery complications. Maternal history is negative for premature or prolonged rupture of membranes, group B Streptococcus colonization, genital herpes, hepatitis B surface antigen, human immunodeficiency virus, and rapid plasma reagin. Laboratory data are significant for leukopenia, thrombocytopenia, disseminated intravascular coagulation, and severe hepatitis. Blood and urine cultures were obtained, but the newborn is not stable enough for lumbar puncture. The incidence of neonatal herpes in the United States is estimated to vary from 1 in 3,000 to 20,000 live births. Postnatal transmission from a parent or other caregiver (often from nongenital infection) occurs in 10% of cases. The clinical presentation is often characterized by sepsis syndrome with pneumonitis, hepatitis, severe coagulopathy, and encephalitis. Skin lesions may be absent at disease onset, but approximately 66% of disseminated disease cases have cutaneous vesicles. Skin vesicles may be absent in disseminated disease, as seen in the patient in this vignette. Infants must be closely monitored with serial complete blood cell counts for neutropenia while receiving acyclovir suppressive therapy. In a term infant, the differential diagnosis of sepsis must include late-onset bacterial sepsis. However, the clinical presentation and laboratory findings in the neonate described in this vignette are more consistent with disseminated herpes than methicillin-resistant Staphylococcus aureus infection. Initiating acyclovir therapy in conjunction with intravenous ampicillin and cefotaxime to cover for common pathogens associated with neonatal sepsis (such as group B Streptococcus, Escherichia coli, Listeria monocytogenes, or Enterococcus) is the preferred response over vancomycin for empiric treatment of this infant. Candidiasis is a major cause of morbidity and mortality among low birth-weight infants in the neonatal intensive care unit. However, invasive fungal infection would be very unusual in an otherwise healthy term infant during the first weeks after birth. Thus, amphotericin therapy to empirically treat fungal infection would not be recommended for the neonate in this vignette. Rarely, influenza infection in infants can manifest as a sepsis-like syndrome associated with pneumonia; however, initiating empiric oseltamivir would not be a preferred response in this case. Thus, trimethoprim-sulfamethoxazole therapy to empirically treat P jirovecii pneumonia would not be recommended. Infants with neonatal herpes simplex virus infection must receive oral acyclovir suppressive therapy for 6 months after completion of intravenous acyclovir for acute herpes simplex virus infection. She reports no pain or fussiness with the episodes and no correlation with changes in maternal diet. The resident asks what education she should provide this mother about when regurgitation is likely to resolve. These terms include regurgitation, gastroesophageal reflux, gastroesophageal reflux disease, rumination, and vomiting. Regurgitation is the involuntary effortless return of stomach contents to the mouth and is common in infants. Regurgitation is associated with the transient relaxation of the lower esophageal sphincter. Regurgitation is a physiologic process that resolves in 95% of infants by 12 months of age. Gastric distention, as seen in infants feeding large volumes, increases the frequency of the the lower esophageal sphincter relaxation and therefore increases regurgitation around meal times. Vomiting is defined by a central nervous system reflex involving skeletal muscles and the autonomic nervous system resulting in the forcible expulsion of gastric contents through the mouth. This process is accomplished with coordination of musculature in the diaphragm, small bowel, stomach, and esophagus. Gastroesophageal reflux is the regurgitation of stomach contents into the esophagus without associated symptoms. It occurs in all infants, children, and adults and is not associated with harm in most people. Gastroesophageal reflux disease is regurgitation of stomach contents into the esophagus with associated tissue damage or symptoms (eg, pain, failure to thrive, irritability, cough, dental erosions). Rumination is the effortless, voluntary, habitual regurgitation of recently swallowed stomach contents without associated heartburn, discomfort, or nausea. Rome criteria for diagnosis include repetitive contractions of the abdominal muscles, diaphragm, and tongue followed by regurgitation of stomach contents, which are then expectorated or chewed and re swallowed. Three of the following criteria are required for diagnosis: onset between 3 and 8 months of age; does not respond to management for gastroesophageal reflux disease, anticholinergics, formula changes, gavage, or gastrostomy tube feedings; unaccompanied by signs of nausea or distress; and does not occur during sleep and when the infant is interacting with individuals. Complications of rumination can include weight loss, electrolyte abnormalities, malnutrition, dental erosions, halitosis, and inability to function. Rumination variations: aetiology and classification of abnormal behavioural responses to digestive symptoms based on high resolution manometry studies. Pediatric Neurogastroenterology: Gastrointestinal Motility and Functional Disorders in Children. The girl was running barefoot through the grass at a local park when she suddenly began screaming and sat down on the ground, clutching her right foot. Her mother noticed several bees flying around her and saw a dead insect on the ground near the girl. She collected the dead insect in a plastic bag, and drove the girl to urgent care center for evaluation. You note no stridor, angioedema, drooling, or facial swelling on physical examination, and she displays no signs of respiratory distress. She has localized erythema at the site of her recent sting, but no other findings of systemic illness. Pediatric providers must recognize the clinical findings associated with life-threatening reactions to Hymenoptera stings, as well as reactions that require no further intervention in children. Bees (Apidae), wasps (Vespidae), and ants (Formicidae) are insects that comprise the order known as Hymenoptera. The most common reactions to Hymenoptera stings in children include localized pain, itching, erythema, and mild swelling at the site of the sting, without any signs of systemic illness (as observed in the girl in the vignette). In such cases, the recommended treatment involves removing the stinger (using tweezers or gently scraping the skin), application of cool compresses or ice packs, mild oral analgesics (eg, acetaminophen), and oral antihistamines to help alleviate pruritus. Minor local reactions to Hymenoptera stings generally resolve within a few hours to a few days. More severe local reactions to Hymenoptera stings can present with marked swelling, redness, and pain near the sting site. This may prompt clinicians to suspect cellulitis, but infection is unlikely in the first 48 hours after a sting, and antibiotics are generally not required. Large localized reactions to Hymenoptera stings can take more than a week to resolve, and affected patients often have similar reactions with future stings. Patients who have this type of local response to Hymenoptera stings have a relatively low risk of future anaphylactic reactions (10%). These cases typically involve rapid development of symptoms involving 2 or more body systems, which may include skin and/or mucous membrane (urticaria, angioedema, flushing), respiratory (wheezing, cough, stridor, dyspnea), cardiovascular (hypotension, dizziness, syncope, shock), and gastrointestinal (colicky abdominal pain, nausea, vomiting, diarrhea) manifestations. Reactions of this type are fortunately rare; anaphylaxis due to insect stings occurs in 0. Children presenting with anaphylaxis should be treated immediately with intramuscular epinephrine and aggressive supportive measures to maintain the airway, breathing, and circulation. In addition, all children presenting with acute anaphylaxis should be transported to an emergency department by trained emergency medical personnel. Oral corticosteroids may be warranted as a component of treatment in patients with either severe local reactions or acute anaphylaxis following Hymenoptera stings. The girl in the vignette presents with a minor local reaction, therefore, treatment with systemic corticosteroids is not indicated in her case.

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References

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