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D iag nosis delay in patients with ankylosing spondylitis possible reasons and proposals for new diagnostic criteria. C linical relev ance of C-reactive protein in axial involvement of ankylosing spondylitis. The European Sp ondylart h rop at h y St u dy G rou p p reliminary crit eria for t h e classification of spondylarthropathy. Th e relat ionsh ip b et w een K leb siella infect ion and ankylosing spondylitis. Prevalence of Lumbar Facet Arthrosis and Its Relationship to Age, Sex, and Race An Anatomic Study of Cadaveric Specimens. Th e clinical u t ilit y of comp u t ed t omog rap h y comp ared t o conv ent ional radiog rap h y in diag nosing sacroiliitis. In iximab inhibits bone resorption by circulating osteoclast p recu rsor cells in p at ient s w it h rh eu mat oid art h rit is and ankylosing spondylitis. Treat ment of ankylosing sp ondylit is b y inh ib it ion of t u mor necrosis fact or alp h a. Long-term disab ilit y and p rolong ed sick leav es as ou t come measu rement s in ankylosing sp ondylit is. Results of surgical correct ion of kyp h ot ic deformit ies of t h e sp ine in ankylosing spondylitis on the basis of the modified arthritis impact measurement scales. Magnetic resonance imaging of in ammatory lesions in the spine in ankylosing spondylitis clinical trials is paramagnetic contrast medium necessary. Continuation of group physical therapy is necessary in ankylosing spondylitis results of a randomized controlled trial. A double-blind, placebo-controlled trial of low dose in iximab in ankylosing spondylitis. The appearance of t h e p iriformis mu scle syndrome in comp u t ed t omog rap h y and mag net ic resonance imag ing. Fatigue in ankylosing spondylitis its prevalence and relationship to disease activity, sleep, and other factors. Association between the interleukin 23 receptor and ankylosing spondylitis is confirmed by a new K case-control study and meta-analysis of published series. L at issimu s dorsi 4 5 6 2 7 1 2 6 3 9 7 6 8 10 Shoulder & Arm 9 126 Orthopedic Conditions Infraspinatus 14 13 Anterior view of right shoulder B icep s long h ead t endon Transv erse h u meral lig ament Scap u la G lenoid lab ru m A rt icu lar cap su le H u meru s Vizniak Su b scap u lar b u rsa Weak Deep neck e or Tight Pectoralis major Weak Abdominal muscles Tight Iliopsoas Scapulocostal musculature Tight Erector spinae Weak Glut. D iag nost ic accu racy of clinical t est s for su b acromial imp ing ement syndrome: a systematic review and meta-analysis. Shoulder impingement syndrome: relat ionsh ip s b et w een clinical, fu nct ional, and radiologic findings. A rt h roscop ic su b acromial decomp ression: acromiop last y versus bursectomy alone-does it really matter A syst emat ic rev iew. Th e p at h olog y and t reat ment of recu rrent dislocation of the shoulder oint. Point-of-care ultrasound diagnosis and t reat ment of p ost erior sh ou lder dislocat ion. A Prosp ect iv e C omp arison of Procedural Sedation and ltrasound-guided Interscalene N erv e B lock for Sh ou lder R edu ct ion in t h e E merg ency Department. The short-term effect s of t h oracic sp ine t h ru st manip u lat ion on p at ient s w it h sh ou lder imp ing ement syndrome. C h alidis B, Sach inis N, D imit riou C, Pap adop ou los P, Samoladas E, Pou rnaras J. Blind or ltrasound- uided Corticosteroid In ections and Short-Term Response in Subacromial Impingement Syndrome A Randomized, Double-Blind, Prospective Study. A rt h roscop ic su b acromial decompression acromioplasty versus bursectomy alone-does it really matter A systematic review. C onserv at iv e or su rg ical t reat ment for su b acromial impingement syndrome A systematic review. E v alu at ion of p rop ofol and remifent anil for int rav enou s sedat ion for redu cing sh ou lder dislocat ions in t h e emerg ency dep art ment. Medial displacement of the b icep s b rach ii t endon: ev alu at ion w it h dynamic sonog rap h y during maximal external shoulder rotation. A rt h roscop ic su t u re rep air of su p erior lab ral det ach ment lesions of t h e sh ou lder. A rt h roscop ic t reat ment of ant erior sh ou lder inst ab ilit y u sing knot less su t u re anch ors. A cadav eric model of t h e t h row ing sh ou lder: a p ossib le et iolog y of su p erior labrum anterior-to-posterior lesions. Su rg ical v ersu s non-surgical treatment for acute anterior shoulder dislocation. Th e effect iv eness of manu al t h erap y in t h e manag ement of mu scu loskelet al disorders of t h e sh ou lder: a systematic review. A ssociat ion of sonog rap h ically det ect ed su b acromial/ su b delt oid b u rsal effusion and intraarticular uid with rotator cuff tear. Sports activity after arthroscopic superior labral repair using suture anchors in overheadthrowing athletes. Specificity and sensitivity of the anterior slide t est in t h row ing at h let es w it h su p erior g lenoid lab ral t ears. Th e p assiv e comp ression t est : a new clinical t est for su p erior lab ral t ears of t h e sh ou lder. A t yp ical p at t ern of acu t e sev ere sh ou lder p ain: cont rib u t ion of sonography. Point-of-Care ltrasound Facilitates D iag nosing a Post erior Sh ou lder D islocat ion. Intraarticular lidocaine versus int rav enou s analg esic for redu ct ion of acu t e ant erior sh ou lder dislocat ions. Su p erior lab ral lesions in t h e sh ou lder: p at h oanat omy and su rg ical manag ement. Limited sensitivity of u lt rasou nd for t h e det ect ion of rot at or cu ff t ears. Fluoroscopically guided supraglenoid tubercle steroid in ections for the management of biceps tendonitis. Th e ant erior cap su lar mech anism in recu rrent ant erior dislocat ion of t h e sh ou lder. Morp h olog ical and clinical st u dies w it h sp ecial reference t o t h e g lenoid lab ru m and glenohumeral ligaments. A nt erior acromiop last y for t h e ch ronic imp ing ement syndrome in t h e sh ou lder: a p reliminary rep ort. Th e act iv e comp ression t est : a new and effect iv e t est for diag nosing labral tears and acromioclavicular oint abnormality. Biceps t endinit is cau sed b y an ost eoch ondroma in t h e b icip it al g roov e: a rare cau se of sh ou lder p ain in a b aseb all p layer. E ffect of lesions of t h e su p erior p ort ion of t h e g lenoid lab ru m on g lenoh u meral t ranslat ion. C ont rib u t ions of myofascial p ain in diag nosis and t reat ment of sh ou lder p ain. A nt erior sh ou lder dislocat ions in p ediat ric p at ient s: are rou t ine p reredu ct ion radiog rap h s necessary. E lb ow p ain w it h g rip / w rist mot ions Palpation ( may b e done aft er R O M assessment ) medial ep icondyle ex t ensor t endon u lnar g roov e anconeu s med. Manip u lat iv e int erv ent ions for redu cing p u lled elb ow in young children.
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Quinolones are contraindicated during all stages of pregnancy due to the risk of arthropathy. A healthy diet during pregnancy helps reduce the risk of having an infant of low birth weight who is at increased risk of poor health. A good diet contains a wide variety of foods including bread, cereals, pasta, rice and potatoes; fruit and vegetables; lean meat; fish and pulses; and reduced fat milk and dairy products. This is a general term for the infection of the upper genital tract including uterus, fallopian tubes and ovaries. Symptoms include: I I I I I I lower abdominal pain (usually most prominent symptom) dyspareunia abnormal vaginal bleeding abnormal vaginal discharge dysuria nausea and vomiting (rare in acute infection). A suggested alternative is ofloxacin 400 mg orally twice daily plus oral metronidazole 400 mg twice daily, both for 14 days. Broad-spectrum antibiotics all have the potential to cause gastrointestinal side-effects, such as nausea, vomiting and diarrhoea. Consider using a different antibiotic if the person has a true penicillin allergy, as cephalosporins show cross-reactivity to penicillins in about 8% of people. Precipitation of seizures is rare unless the person is already prone to epilepsy or related conditions. I 164 I P ha r ma c y Ca s e St ud ie s Metronidazole may cause gastrointestinal effects and react with alcohol. Common adverse effects include a metallic taste and gastrointestinal irritation (in particular nausea and vomiting). Some people taking oral metronidazole experience disulfiramlike reactions to alcohol (flushing, increased respiratory rate, increased pulse rate). Thus, people taking metronidazole should be advised of the possible consequences of drinking alcohol. I 4c Metronidazole is included to improve coverage for anaerobes as initial infection with Chlamydia or Neisseria gonorrhoea can cause epithelial damage, allowing other organisms to enter the cervix and cause ascending infection. Paracetamol is a safe and effective analgesic and antipyretic that is suitable for most patients. Codeine (alone or in combination with regular paracetamol) can be helpful when paracetamol alone is insufficient. Prescribing it separately offers greater flexibility in dosing and hence pain control. The need to avoid intercourse until both they and their partner(s) have completed treatment. The possible long term health implications for their health and the health of their partner(s). Endometriosis is a condition where endometrial tissue is found outside the uterus. A reflux of menstruation occurs in many women but in endometriosis refluxed cells implant in the pelvis, bleed in response to cyclic hormone stimulation and increase in size. It is often cyclic and responds to menstruation, but over time pain becomes a chronic pain syndrome which is acyclic and only disappears in pregnancy or menopause. Women can also have advanced lesions with tissue destruction and adhesions and may be asymptomatic. A study has confirmed prevalence among first-, second- and third-degree relatives, which suggests this disorder has a genetic basis. Women with severe chronic pain have a more advanced stage of disease at initial diagnosis. Surgical treatment by laparoscopic ablation of endometriotic lesions plus adhesiolysis may improve fertility. Hormonal treatments should not be used for endometriosis in women with fertility problems as they tend to lead to ovarian suppression. The hypothalamus causes pulsed releases of gonadotrophin-releasing hormone (GnRh). This results in the anterior pituitary producing follicle-stimulating hormone and luteinising hormone, which in the ovaries results in the production of oestrogens and progestogens. The different hormone treatments work by affecting different parts of this cascade. The end-result is to reduce the amount of oestrogen that is made or to block its actions in endometrial cells. Although oestrogen is present, the progestogen thins the endometrium and results in sparse bleeding at the regular withdrawals. This practice is off-licence but the regimen is safe, well tolerated and acceptable by women. Adverse effects include nausea, vomiting, headache, breast tenderness, changes in body weight, fluid retention and thrombosis. They induce endometrial atrophy and reduce oestrogen levels by inhibiting ovulation. It is licensed to be taken for 90 days although some clinicians advise continued use if adverse effects are minimal and symptoms are well controlled. Adverse effects include; irregular bleeding, bloating, skin changes, mood changes and weight gain. They have androgenic, anti-oestrogenic and anti-progestogenic activity and usually cause amenorrhoea and induce a postmenopausal state. I I Danazol is licensed to be taken continuously for up to six months but can only be used when other treatments have failed. It does not reduce bone mineral density as its anabolic effects counteract the effect of lowered oestrogen levels. It has similar actions to danazol but has a longer half-life, allowing twice weekly instead of daily dosing. Both are poorly tolerated because of androgenic adverse effects, which include weight gain, hirsutism, acne, mood changes and occasionally deepening of the voice, which may be irreversible. This is followed by anovulation, markedly reduced oestrogen levels and amenorrhoea, inducing a postmenopausal state and regression of endometrial deposits. As these need daily dosing they are not commonly prescribed, as psychologically the patient is constantly reminded of the disease. Goserelin, 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 hypooestrogenic adverse effects such as bone loss and hot flushes. Other adverse effects of GnRh analogues include insomnia, reduced libido, vaginal dryness and headaches. With buserelin or naferelin, if a nasal decongestant is 168 P ha r ma c y Ca s e St ud ie s 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. Eclampsia is defined as the occurrence of one or more convulsions superimposed on pre-eclampsia. Pre-eclampsia is pregnancy-induced hypertension in association with proteinuria (>0. 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 significant proteinuria (at least 1 g/L). List the clinical features of severe pre-eclampsia (in addition to hypertension and proteinuria). 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. Antihypertensive treatment should be started if systolic blood pressure >160 mmHg or diastolic >110 mmHg.
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One hope fizzled when authorities caught James Lewis, who was wanted for allegedly writing a $1 million extortion letter to Johnson & Johnson, but could not connect him with the actual poisonings. With time the number of tips has dwindled, the Tylenol hot line has been disconnected, and the special task force has shrunk from more than 100 agents to 20. Since the company switched to tamper-resistant packaging, Tylenol has slowly climbed from 4 percent of the analgesic market to 24 percent - just 11 percent less than when the bizarre killings began. Even more chilling, the seals on both the box and the Tylenol bottle itself seemed unbroken. Had the madman who poisoned seven Chicago-area residents with cyanide-laced Tylenol in 1982 returned? Whatever the answer, the murderer has obviously raised "over-the-counter terrorism" to a more sophisticated level. Just as in the Chicago case, the federal Food and Drug Administration warned consumers nationwide not to take any Tylenol capsules until further notice. More than a dozen states banned sales of the product, and health officials from coast to coast fielded calls from anxious consumers. The poisoned capsules had been made at different plants, one in Pennsylvania, one in Puerto Rico, and had turned up only in the New York area, leading authorities to believe they were looking for a local killer. Buttressing this theory was the fact that cyanide would have eaten through the capsules in 8 to 10 days, thus all but eliminating the possibility contamination occurred at the plant or somewhere else early in the distribution chain. Illinois authorities offered to share some 6,000 leads with New York investigators. Most involved disgruntled employees of wholesalers, distribution firms and drugstore chains, but none had produced solid leads by 1984 when the Chicago Tylenol task force disbaned in frustration. Johnson & Johnson, meanwhile, braced for a new round of shattered consumer confidence. Secret Service agents arrested three people in New Rochelle on charges of credit-card fraud and one suspect confessed he had written an extortion letter from "Tylenol Killer #2" demanding $2 million from Johnson & Johnson. Lewis himself is in prison on the extortion charge, and most investigators have concluded he did not commit the murders. The larger danger seemed to be the chance of still more copycat consumer murders, perhaps involving other over-the-counter products. A psychopath could poison meat or fruit or vegetables, which are normally sold with even less protective packaging than pharmaceuticals. Aware of the deadly possibilities, authorities could only redouble their efforts to find the killer before he struck again, and hope against hope that he would not serve as a murderous example for someone else. No one has ever been officially charged with the killings - investigators still get 10 or 15 leads a year - but one key suspect, James Lewis, is now serving a 10-year prison sentence for attempting to extort $ 1 million from Johnson & Johnson. Lewis gave authorities an elaborate description of how the poisoned-Tylenol murders "might" have been committed, but he suddenly stopped the interviews and refused to take a liedetector test, which he called "voodoo electronics. Thirteen years ago, seven people in the Chicago area died after taking Tylenol capsules that had been randomly laced with cyanide. As a result of the case, regulations were adopted requiring tamper-resistant packaging. Comprehensive and dependable education content-delivered whenever and however you need it. Bernadette Webster, Director of Publishing; Ray Golaszewski, Publishing Operations Manager; Linda M. No part of this work covered by the copyright herein may be reproduced or used in any form or by any means-graphic, electronic, or mechanical, including photocopying, recording, taping, Web distribution, or information storage and retrieval systems-without the prior written permission of the publisher. For permission to use material from this text or product, complete the Permission Request Form at. As a leading publisher, we are aware that our business has a direct impact on vital resources-most especially the trees that are used to make our books. Most programs are offered by schools of allied health, academic health centers, medical schools, or 4-year colleges. Completing the comprehensive practice tests in this book will help you pass this exam. To get the most out of this book, take the time to read each section carefully and thoroughly. Take this test under normal testing conditions; go to a quiet setting and time yourself. Each chapter begins with a review of the question type, tips for answering those particular questions, and practice questions with answer explanations. The multiple-choice questions in the practice exercises are just like those on the actual test. Even if you answered the questions correctly, you may discover a new tip in the explanation that will help you answer other questions. The questions on the practice tests in this book are not the actual questions that you will see on the exam. The actual test is administered in 4 blocks of 90 questions with 90 minutes allowed for each block. Master the Physician Assistant National Exam will help you score high and prepare you for everything you need to know on the day of the exam and beyond it. Your feedback will help us make educational dreams possible for you-and others like you. To this end, it includes several features to make your preparation more efficient. Overview Each chapter begins with a bulleted overview listing the topics covered in the chapter. Summing It Up Each chapter ends with a point-by-point summary that reviews the most important items in the chapter. Responsibilities of a physician assistant How do physicians and physician assistants differ? They are widely employed in medical practices ranging from dermatology, pediatrics, family practice, and obstetrics and gynecology. For diagnosis and treatment, the patient must be referred to a more experienced physician with a broader range of knowledge encompassing the digestive system. Physicians must then complete up to 7 years of graduate medical education, including a hospital residency, in which the doctors train in a specific field. If physicians choose to change their area of specialization, they must return to school and reenter a residency program for training. For example, if after practicing obstetrics and gynecology for several years, a physician decides to work as a pathologist, he or she must reenroll full time (most likely leaving the obstetrics/gynecology practice) in a pathology residency to train for the new area of expertise. Physician assistants should not be confused with medical assistants, who commonly work in medical practices. This extra training is reflected in the salary difference between the two positions. Medical assistants earn an average of $25,000 per year, while physician assistants earn approximately $75,000 per year. Once they completed this program, they were allowed to run the Emory University and Grady Hospitals in Atlanta, Georgia, on a short-term basis. In a 1961 issue of the Journal of the American Medical Association, a physician named Dr. Charles Hudson asserted that former military corpsmen should be allowed to act as "mid-level" providers when they returned home from active duty. Some specialize in dermatology, radiology, otolaryngology, psychiatry, or pathology. This often requires patience, since some patients may have difficulty communicating or may have a limited proficiency in English. They must get along with a variety of employees-ranging from medical assistants to supervising physicians-and have great respect for their colleagues. Many medical offices have now replaced paper-and-pencil medical charts with electronic data that is accessed via laptop computer when a provider sees a patient. They must also be reliable, flexible, and cooperative to help ensure that the health-care team is providing the best possible service to patients at all times. Since many medical offices only maintain electronic records, medical professionals must possess the skills to access, amend, and add to the electronically stored information. They must also use the available resources to help maintain a wide range of medical information and to stay up-to-date on current medical research. Most of these programs are affiliated with accredited 2- and 4-year medical colleges or universities or schools of allied health. Regardless of the degree obtained, all candidates are held to the same medical standards, must pass the same initial certifying exam, will take at least 100 hours of continuing medical education every 2 years, and must sit for the same recertifying exam by the end of the sixth year of certification.
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When hypnotic drug therapy is appropriate for severe insomnia, hypnotics should be prescribed for short periods only. There is no compelling evidence to distinguish between zaleplon, zolpidem, zopiclone or the shorter-acting benzodiazepine hypnotics. It is reasonable to prescribe the drug whose cost is lowest, other things being equal. Switching from one hypnotic to another should only be done if a patient experiences an idiosyncratic adverse effect. Patients who have not benefited from one of these hypnotic drugs should not be prescribed any of the others. Case history A 67-year-old widow attended the Accident and Emergency Department complaining of left-sided chest pain, palpitations, breathlessness and dizziness. Relevant past medical history included generalized anxiety disorder following the death of her husband three years earlier. She had been prescribed lorazepam, but had stopped it three weeks previously because she had read in a magazine that it was addictive. Examination revealed no abnormality other than a regular tachycardia of 110 beats/minute, dilated pupils and sweating hands. Question 1 Assuming a panic attack is the diagnosis, what is a potential precipitant? Buspirone (note that buspirone, although anxiolytic, is not helpful in benzodiazepine withdrawal and may also cause tachycardia). It can cause nausea, flushing, anxiety and fits, so is not routinely used in benzodiazepine overdose which seldom causes severe adverse outcome. Useful as a hypnotic in the elderly because its short action reduces the risk of severe hangover, ataxia and confusion the next day. It is effective in acute withdrawal syndrome in alcoholics, but its use should be carefully supervised and treatment limited to a maximum of nine days. Its use has not been associated with addiction or abuse, but may be a less potent anxiolytic than the benzodiazepines. Cloral derivatives have no advantages over benzodiazepines, and are more likely to cause rashes and gastric irritation. Benzodiazepines in clinical practice: consideration of their long-term use and alternative agents. The onset is often in adolescence or young adulthood and the disease is usually characterized by recurrent acute episodes which may develop into chronic disease. The introduction of antipsychotic drugs such as chlorpromazine revolutionized the treatment of schizophrenia so that the majority of patients, once the acute symptoms are relieved, can now be cared for in the community. Neurodevelopmental delay has been implicated and it has been postulated that the disease is triggered by some life experience in individuals predisposed by an abnormal (biochemical/anatomical) mesolimbic system. The concept of an underlying neurochemical disorder is advanced by the dopamine theory of schizophrenia, summarized in Box 19. About 30% of patients with schizophrenia respond inadequately to conventional dopamine D2 receptor antagonists. The D4 receptor is localized to cortical regions and may be overexpressed in schizophrenia. Regional dopamine differences may be involved, such as low mesocortical activity with high mesolimbic activity. Amphetamine (which increases dopamine release) can produce acute psychosis that is indistinguishable from acute schizophrenia (positive symptoms). D2 agonists (bromocriptine and apomorphine) aggravate schizophrenia in schizophrenic patients. L-Dopa can cause hallucinations and acute psychotic reactions and paranoia, but does not cause all the features of these conditions. After an acute episode, reduce the oral dose gradually and overlap with depot treatment. Give a test dose in case the patient is allergic to the oil vehicle or very sensitive to extrapyramidal effects. Repeated adminstration causes an increase in D2-receptor sensitivity due to an increase in abundance of these receptors. This appears to underlie the tardive dyskinesias that are caused by prolonged use of the conventional antipsychotic drugs. Tardive dyskinesia consists of persistent, repetitive, dystonic athetoid or choreiform movements of voluntary muscles. Usually the face and mouth are involved, causing repetitive sucking, chewing and lip smacking. Emotional flattening is common, but it may be difficult to distinguish this feature from schizophrenia. Depression may develop, particularly following treatment of hypomania, and is again difficult to distinguish confidently from the natural history of the disease. It is due to intrahepatic cholestasis and is a hypersensitivity phenomenon associated with eosinophilia. Ocular disorders during chronic administration include corneal and lens opacities and pigmentary retinopathy. These disappear on withdrawal of the drug and may not recur if the drug is reinstated. Blood dyscrasias are uncommon, but may be lethal, particularly leukopenia and thrombocytopenia. The incidence of agranulocytosis is approximately 1 in 10 000 patients receiving chlorpromazine. Its clinical features are rigidity, hyperpyrexia, stupor or coma, and autonomic disorder. It responds to treatment with dantrolene (a ryanodine receptor antagonist that blocks intracellular Ca2 mobilization). Impaired temperature control, with hypothermia in cold weather and hyperthermia in hot weather. The most common serious reactions were fits, coma, severe hypotension, leukopenia, thrombocytopenia and cardiac arrest. A 50-year-old woman whose schizophrenia is treated with oral haloperidol is admitted to the Accident and Emergency Department with a high fever, fluctuating level of consciousness, muscular rigidity, pallor, tachycardia, labile blood pressure and urinary incontinence. They have multiple metabolites and their large apparent volumes of distribution (Vd) (e. In comparison to the conventional antipsychotics where potency is closely related to D2 receptor blockade, atypical antipsychotics bind less tightly to D2 receptors and have additional pharmacological activity which varies with the drug. Efficacy against negative symptoms, as well as less extrapyramidal side effects, are characteristic. Careful dose titration reduces the risk of adverse effects, but extrapyramidal side effects are common at high doses. It is available as an intramuscular injection for acute control of agitation and disturbed behaviour. Weight gain and, more worryingly, an increased incidence of stroke in elderly patients with dementia have been reported wih both risperidone and olanzapine. It is not associated with extrapyramidal effects, prolactin secretion or weight gain. The control of hypomanic and manic episodes with chlorpromazine is often dramatic. Case history A 60-year-old man with schizophrenia who has been treated for 30 years with chlorpromazine develops involuntary (choreo-athetoid) movements of the face and tongue. Question 3 Name three other drug-induced movement disorders associated with antipsychotic drugs. Lorazepam by mouth or parenteral injection is most frequently used to treat severely disturbed behaviour as an in-patient.
- Warkany syndrome
- Supraumbilical midabdominal raphe and facial cavernous hemangiomas
- Simian B virus infection
- Sinus cancer
- Anterior horn disease
- Cardiac arrest
- Eosinophilic lymphogranuloma
- Xeroderma pigmentosum, type 7
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Its aetiology is not well understood, but there are four major factors of known importance: 1. Prostaglandin E2 (the principal prostaglandin synthesized in the stomach) is an important gastroprotective mediator. It inhibits secretion of acid, promotes secretion of protective mucus and causes vasodilatation of submucosal blood vessels. Agents such as salicylate, ethanol and bile impair the protective function of this layer. Acid diffuses from the lumen into the stomach wall at sites of damage where the protective layer of mucus is defective. The presence of strong acid in the submucosa causes further damage, and persistence of H ions in the interstitium initiates or perpetuates peptic ulceration. H ions are cleared from the submucosa by diffusion into blood vessels and are then buffered in circulating blood. Although commonly found in the gastric antrum, it may also colonize other areas of the stomach, as well as patches of gastric metaplasia in the duodenum. It has been shown that the speed of ulcer healing obtained with acid-suppressing agents is accelerated if H. Documented duodenal or gastric ulcerations should be treated with an H2-blocker or proton-pump inhibitor. In addition, it is thought that antacid may increase lower oesophageal sphincter tone and reduce oesophageal pressure. In general terms, antacids should be taken approximately one hour before or after food, as this maximizes the contact time with stomach acid and allows the antacid to coat the stomach in the absence of food. Most regimens include a combination of acid suppression and effective doses of two antibiotics. Eradication should be confirmed, preferably by urea breath test at a minimum of four weeks post-treatment. Drug interactions Magnesium and aluminium salts can bind other drugs in the stomach, reducing the rate and extent of absorption of antibacterial agents such as erythromycin, ciprofloxacin, isoniazid, norfloxacin, ofloxacin, pivampicillin, rifampicin and most tetracyclines, as well as other drugs such as phenytoin, itraconazole, ketoconazole, chloroquine, hydroxychloroquine, phenothiazines, iron and penicillamine. H2-receptors stimulate gastric acid secretion and are also present in human heart, blood vessels and uterus (and probably brain). There are a number of competitive H2-receptor antagonists in clinical use, which include cimetidine and ranitidine. Because each drug is so widely prescribed, separate sections on their individual adverse effects, pharmacokinetics and interactions are given below, followed by a brief consideration of the choice between them. It is essential to exclude carcinoma endoscopically, as H2-blockers can improve symptoms caused by malignant ulcers. Without gastric acid, the functions of which include providing a barrier to infection, patients on H2-antagonists and proton-pump inhibitors are predisposed to infection by enteric pathogens and the rate of bacterial diarrhoea is increased. Oesophagitis may be treated with H2-antagonists, but proton-pump inhibitors are more effective. In cases of acute upper gastrointestinal haemorrhage and stress ulceration, the use of H2-blockers is rational, although their efficacy has not been proven. Replacement of pancreatic enzymes in steatorrhoea due to pancreatic insufficiency is often unsatisfactory due to destruction of the enzymes by acid and pepsin in the stomach. The usual oral dose of cimetidine is 400 mg bd or 800 mg nocte, while for ranitidine it is 150 mg bd or 300 mg nocte to treat benign peptic ulceration. Cimetidine transiently increases serum prolactin levels, but the significance of this effect is unknown. Decreased libido and impotence have occasionally been reported during cimetidine treatment. Chronic cimetidine administration can cause gynaecomastia, which is reversible and appears with a frequency of 0. Rapid intravenous injection of cimetidine has rarely been associated with bradycardia, tachycardia, asystole or hypotension. Absorption of ketoconazole (which requires a low pH) and itraconazole is reduced by cimetidine. Metabolism of several drugs is reduced by cimetidine due to inhibition of cytochrome P450, resulting in raised plasma drug concentrations. Interactions of potential clinical importance include those with warfarin, theophylline, phenytoin, carbamazepine, pethidine and other opioid analgesics, tricyclic antidepressants, lidocaine (cimetidine-induced reduction of hepatic blood flow is also a factor in this interaction), terfenadine, amiodarone, flecainide, quinidine and fluorouracil. Cimetidine inhibits the renal excretion of metformin and procainamide, resulting in increased plasma concentrations of these drugs. However, unlike cimetidine, ranitidine does not bind to androgen receptors, and impotence and gynaecomastia in patients on high doses of cimetidine have been reported to resolve when they were switched to ranitidine. Cardiovascular effects have been even more infrequently reported than with cimetidine. Drug interactions Ranitidine has a lower affinity for cytochrome P450 than cimetidine and does not inhibit the metabolism of warfarin, phenytoin and theophylline to a clinically significant degree. Adverse effects Diarrhoea, abdominal pain, nausea and vomiting, dyspepsia, flatulence, abnormal vaginal bleeding, rashes and dizziness may occur. The most frequent adverse effects are gastrointestinal and these are usually dose dependent. Cimetidine and ranitidine are most commonly prescribed and have been available for the longest time. Cimetidine is the least expensive, but in young men who require prolonged treatment ranitidine may be preferable, due to a lower reported incidence of impotence and gynaecomastia. Ranitidine is also preferable in the elderly, where cimetidine occasionally causes confusion, and also when the patient is on drugs whose metabolism is inhibited by cimetidine (e. Contraindications Pregnancy (or desired pregnancy) is an absolute contraindication to the use of misoprostol, as the latter causes abortion. It also stimulates mucus production and may chelate with pepsin, thus speeding ulcer healing. Several studies have shown it to be as active as cimetidine in the healing of duodenal and gastric ulcers after four to eight weeks of treatment. Bismuth chelate elixir is given diluted with water 30 minutes before meals and two hours after the last meal of the day. This liquid has an ammoniacal, metallic taste and odour which is unacceptable to some patients, and chewable tablets can be used instead. Ranitidine bismuth citrate tablets are also available for the treatment of peptic ulcers and for use in H. Examples are omeprazole, esomeprazole, lansoprazole, pantoprazole and rabeprazole. As yet there do not appear to be any clinically significant drug interactions with pantoprazole, whereas omeprazole inhibits cytochrome P450 and lansoprazole is a weak inducer of cytochrome P450. Adverse effects Adverse effects include blackening of the tongue, teeth and stools (causing potential confusion with melaena) and nausea. Urine bismuth levels rise with increasing oral dosage, indicating some intestinal absorption. Although with normal doses the blood concentration remains well below the toxic threshold, bismuth should not be used in renal failure or for maintenance treatment. It is a basic aluminium salt of sucrose octasulphate which, in the presence of acid, becomes a sticky adherent paste that retains antacid efficacy. This material coats the floor of ulcer craters, exerting its acid-neutralizing properties locally, unlike conventional antacid gels which form a diffusely distributed antacid dispersion. In addition it binds to pepsin and bile salts and prevents their contact with the ulcer base.
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Malingering is a disorder of exaggerating or fabricating pain or illness for secondary purposes such as avoiding school, avoiding work, obtaining drugs, or obtaining lighter criminal sentences. Patients with this disorder will insist they are ill even when a physical exam does not confirm illness. Glyburide does not cross the placenta, but metformin crosses the placenta in small amounts. Medications for gestational diabetes should only be used if dietary changes fail to address the condition. If symptoms persist and do not respond to diuretic treatment, surgical intervention may be required for resolution of this disorder. Melancholia is characterized by not being able to find pleasure anywhere in life, even during pleasurable experiences. Patients may exhibit suicidal ideations, agitation, anorexia, weight loss, depression, feelings of guilt, and sleep disturbances. These benign neoplasms appear as red, raspberry-like nodules that primarily occur on the exposed areas of the body such as neck, arms, fingers, hands, and legs. These nodules normally appear after injury or surgery but may appear spontaneously. Desmopressin acetate is the most effective medication in treatment of Von Willebrand disease. Betamethisone is given to ensure fetal lung maturity when a hypertensive pregnant female must give birth early. Betamethisone increases the level of surfactant within the lungs of the unborn child, which is critical for lung maturity. Macular degeneration is a disorder characterized by permanent central vision loss. Macular degeneration may simply be caused by old age or by the toxic effects from cholorquine or phenothiazine medications, such as thorazine or compazine. For example, S-T elevation in lead V5 indicates a myocardial infarction occurring in the lateral wall of the heart. Patients will present with progressively worsening shortness of breath, excessive cough, and sputum production. Auscultation of the lungs will reveal decreased breath sounds and early inspiratory crackles. Septic shock is a type of distributive shock that is caused by poorly regulated blood volume. Septic shock is most associated with Gram-negative sepsis in patients who are of advanced age, diabetic, immunosuppressed, and who have recently undergone an invasive procedure. This device reduces the viability and number of sperm that reach the egg and also decreases the movement and number of eggs that reach the uterus. Myasthenia gravis is an autoimmune neuromuscular disease that leads to fluctuating muscle weakness and fatigue. Cholinesterase inhibitors prevent the breakdown of acetylcholine, which increases the levels of the acetylcholine neurotransmitter available to muscle cells. Bunions are the most common deformity of the metatarsophalangeal joint and are more common in women than in men. Patients will complain of toe or foot pain, deformities of the toes, and inability to find shoes that fit properly. X-rays will reveal a deformity of the proximal phalanx at an angle greater than 15 degrees. Dacryocystitis is an inflammation of the lacrimal gland usually caused by obstruction. On a standard electrocardiogram, leads V3 and V4 represent the anterior wall of the heart muscle. For example, S-T depression in lead V4 indicates the presence of myocardial ischemia in the anterior wall of the heart. Classic criteria for primary hypertension are a systolic pressure greater than 140 mmHg or a diastolic pressure greater than 90 mmHg. A 72-hour fecal fat test is commonly used to diagnose the disorder of malabsorption. This test is an evaluation of the function of the liver, gallbladder, pancreas, and 248 Implanon is a form of contraception that requires the implantation of a single rod that releases etonorgestrel at a rate of about 40 mcg/day. Etonorgestrel is a progesterone analog, which inhibits ovulation and changes the cervical mucous and uterine lining. Blepharitis is a condition characterized by chronic inflammation of the eyelid margins. Treatment for this condition should include eyelid scrubs with diluted baby shampoo on cotton-tipped swabs. If infection is suspected, topical antibiotics can also be added to the treatment regimen. Deep venous thrombosis can be effectively evaluated through an ultrasound exam with Doppler. A tension pneumothorax is secondary to a sucking chest wound or pulmonary laceration. Physical exam will reveal impaired ventilation leading comprised cardiac function. It can lead to symptoms such as exertional dyspnea, non-productive cough, orthopnea, and exercise intolerance. Auscultation of the chest reveals a parasternal lift, enlarged apical impulse, diminished first heart sound, an S3 gallop, and an S4 gallop. Chest X-ray should reveal cardiomegaly, bilateral pleural effusions, and perivascular or interstitial edema. Intussesception is defined as the invagination of a proximal segment of the bowel into the portion just distal to it. For pediatric patients with this disorder, a sausagelike mass may be appreciated with an abdominal examination. Diazepam is the indicated course of treatment for individuals who suffer from acute episodes of vertigo. Diazepam should be administered intravenously or rectally for most effective treatment. A d-dimer level is a blood test result that indicates the level of protein fragments present in the blood after a blood clot has been degraded by fibrinolysis. A negative d-dimer level will rule out blood clots immediately, regardless of the symptoms the patient is experiencing. The d-dimer lab test is used to confirm the diagnosis of thrombosis, or blood clots. D-dimer is a small fragment of protein that remains after a blood clot has been degraded by fibrinolyis. A negative lab test for d-dimer completely rules out the possibility of pulmonary embolism. Deep venous thrombosis, also known as thrombophlebitis, is a partial or complete obstruction of a vein in the legs. Patients will present with dull pain in one leg, accompanied by swelling, redness, and tenderness. A d-dimer level greater than 500 ng/dL is an indicating factor for deep venous thrombosis. Methotrexate can be used for treatment of ectopic pregnancies if the ectopic mass is less than 3. For individuals who suffer from severe motion sickness associated with severe vertigo, scopolamine is the most effective treatment. Scopolamine is most often administered via transdermal patch, which releases a dose of 330 mcg per day. A temporal artery biopsy is required to positively confirm a diagnosis of giant cell arteritis. Giant cell arteritis is a systemic, inflammatory condition of the medium and large vessels. Endometriosis is the condition in which the endometrial glands and stroma are found outside the endometrial cavity. Patients may present with dysmenorrhea, painful sexual intercourse, painful bowel movements, and intermittent spotting. This disorder is characterized by redness, inflammation, burning, and eruptions of the skin around the mouth.
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Histamine contributes to the triple response to mechanical stimulation of the skin which consists of localized pallor, which gives way to a wheal (localized oedema caused by increased vessel Atopy Some individuals with a hereditary atopic diathesis have a propensity to develop local allergic reactions if exposed to appropriate antigens, causing hay fever, allergic asthma or urticaria. This is due to antigen combining with mast-cell-associated IgE in the mucosa of the respiratory tract or the skin. Common agents used to treat hay fever include beclometasone, budesonide and fluticasone. Adverse effects the adverse effects of all these preparations are similar, namely sneezing, and dryness and irritation of the nose and throat. Uses Sodium cromoglicate and nedocromil are effective in preventing exercise-induced and allergic asthma (but less effective than inhaled glucocorticosteroids for the latter). Cromoglicate is used as nasal or eye drops for allergic rhinitis and conjunctivitis. Local adverse effects include occasional nasal irritation or transient stinging in the eye. Its rapid action may be life-saving in general anaphylaxis due to insect venom allergy and reaction to drugs. It is effective by virtue of its -agonist activity which reverses vascular dilatation and oedema, and its 2-agonist activity which produces cardiac stimulation and bronchodilatation. Mechanism of action Antihistamines are competitive antagonists of histamine at H1-receptors. Pharmacokinetics Antihistamines are rapidly absorbed from the intestine and are effective within about 30 minutes. Newer agents, such as fexofenadine, cetirizine and loratadine have half-lives that permit once or twice daily dosing. If infection is the cause, the presence of a foreign body should be excluded and appropriate antibacterial therapy prescribed. If the symptoms are due to allergy, the first step in therapy is allergen avoidance and minimization of exposure (e. Short-term use of a nasal decongestant such as pseudoephedrine is effective, but if used for longer periods causes rebound vasomotor rhinitis. Ipratropium bromide administered intra-nasally may be added if rhinorrhoea is the predominant symptom. If symptoms are more chronic, the firstline therapy is intranasal glucocorticosteroids because these are effective against all symptoms, and are more effective than antihistamines or cromoglicate. If rhinorrhoea is the main problem, ipratropium bromide may be added with or without a long-acting antihistamine (e. If these measures are ineffective, consider low-dose intranasal steroids, or immunotherapy or surgery if there is evidence of sinusitis. Used to treat hay fever and urticaria, and also used as therapy for motion sickness. Should not be applied topically for skin irritation, as they may cause dermatitis. Second-generation agents have few or no sedative or ancilliary properties, and are longer acting (e. There are a number of such substances, usually given as mixtures and often containing lipids, extracts of inactivated tubercle bacilli and various mineral salts. The British National Formulary summarizes the recommended schedule of vaccinations. Contraindications Postpone vaccination if the patient is suffering from acute illness. Ensure that the patient is not sensitive to antibiotics used in the preparation of the vaccine (e. Live vaccines should not be given to pregnant women, nor should they be given to patients who are immunosuppressed. Live vaccines should be postponed until at least three months after stopping glucocorticosteroids and six months after chemotherapy. Vaccines generally stimulate the production of protective antibodies or activated T cells. Live vaccine immunization is generally achieved with a single dose, but three doses are required for oral polio (to cover different strains). Live vaccine replicates while in the body and produces protracted immunity, albeit not as long as that acquired after natural infection. When two live vaccines are required (and are not in a combined preparation) they may be given at different sites simultaneously or at an interval of at least three weeks. Inactivated vaccines usually require sequential doses of vaccine to produce an adequate antibody response. The duration of immunity acquired with the use of inactivated vaccines ranges from months to years. Recombinant technology will yield antibodies of consistent quality in the future, but it is a challenge to replicate the diversity present in polyclonal human normal immunoglobulin. It contains antibodies to measles, mumps, varicella, hepatitis A and other viruses. Adverse effects the most common adverse effects occur during the first infusion and are dependent on the antigenic load (dose) given. Examination revealed no abnormalities apart from slight tremor which she said she had noted for the last 48 hours. Answer In this patient, the development of an acute epileptic seizure in the context of a very high ciclosporin trough concentration indicates ciclosporin toxicity; epilepsy is a well-recognized toxic effect of high ciclosporin concentrations. The difficult issue in the case is why she developed high ciclosporin blood concentrations (in the face of normal renal and hepatic function) when she was adamant that there had been no alteration in the daily dose of ciclosporin she was taking, nor had she started any other drugs (prescribed or over-the-counter agents). The patient had her ciclosporin dosing stopped until the concentration was 300 g/L. She had no further fits, her nausea and tremor subsided, and she was then restarted on her normal dose with clear instructions not to drink grapefruit juice. Contraindications Normal immunoglobulin is contraindicated in patients with known class-specific antibody to IgA. An intramuscular injection is given to rhesus-negative mothers up to 72 hours after the birth/abortion. This prevents a subsequent child from developing haemolytic disease of the newborn. Case history A 35-year-old woman had a cadaveric renal transplant for polycystic kidneys two years previously and was stable on her immunosuppressive regimen of ciclosporin, 300 mg twice a day, and mycophenolate mofetil, 1 g twice a day. She went on holiday to southern California for ten days, where she was well, but drank plenty of fluids (but no alcohol) as she was warned about the dangers of dehydration. Following a long return flight, she went to her local hospital and sustained a brief spontaneously remitting epileptic fit in the outpatient department where she was having her blood ciclosporin concentration checked. The fit lasted about one minute and she was taken to the Accident and Emergency Department. The ability of the practitioner to make a correct diagnosis is paramount, and is aided by the ease of biopsy of the abnormal tissue. Adverse reactions to topical or systemic drugs produce a wide variety of skin lesions. Drugs applied topically to the skin may act locally and/or enter the systemic circulation and produce either a harmful or beneficial systemic pharmacological effect.
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Electrocardiographic and oximetric changes during partial complex and generalized seizures. Cardiovascular autonomic functions in well-controlled and intractable partial epilepsies. Acquired cardiac channelopathies in epilepsy: Evidence, mechanisms and clinical significance. Serotonin reuptake inhibitors are associated with reduced severity of ictal hypoxemia in medically refractory partial epilepsy. Association of Child Neurology-Indian Epilepsy Society Consensus Document on Parental Counseling of Children with Epilepsy. In defiance of medical progress, dengue has achieved the notoriety of being an infectious disease that has relentlessly increased in magnitude and geographic reach over the past several decades. The dramatic increase in the magnitude and frequency of dengue has been attributed to unprecedented human population growth, unplanned urbanization and expansion of travel and globalization. Modelling estimates indicated that there are 390 million dengue virus infections annually, with approximately 100 million cases manifesting clinically, with 70% of the actual burden being in Asia . Unexpected surges of dengue case counts have been reported this year in many places, and this phenomenon is likely to pose serious challenges to already overburdened healthcare systems across the world . It is therefore especially critical, now more than ever, that the classification systems for dengue ensure validity and reproducibility for both clinical management and research studies. This classification, despite being evidence-based, was critiqued for underestimating the clinical burden of the infection, and for poorly distinguishing the milder and more severe forms of dengue . This classification was mainly aimed at optimizing the recognition of warning signs early in the disease course, thereby enhancing clinical decision making and disease management. Severe dengue was defined as infection with at least one of the following: severe plasma leakage leading to shock or fluid accumulation, with respiratory distress, severe bleeding, or severe organ impairment. However, this classification fails to identify the precise parameters that define these signs, leading to a great deal of heterogeneity in the use of this system, a problem well-described in a recent systematic review . The sensitivity of this classification to identify severe dengue has ranged between 59-98%, and specificity between 41-99% . It has been argued that the severe dengue entity as defined by the 2009 classification represents a mix of end-stage manifestations involving various clinical pathways, potentially including comorbidities and other iatrogenic factors . Most importantly, the 2009 classification fails to identify standard, quantifiable clinical endpoints which are needed to ensure reproducibility and comparability of research findings, thereby limiting its application in research studies, such as studies aiming to study the safety, efficacy and effectiveness of a dengue vaccine or therapeutic agent. An expert working group assembled in 2015 used the Delphi method of interactive consensus-driven guideline formulation to derive dengue disease severity endpoints for use in clinical trials of dengue therapeutics and vaccine research . Consensus was reached on most parameters including, moderate and severe plasma leakage, bleeding, and organ involvement (liver, heart and neurologic disease) . It is clear that further prospective studies to validate standardized clinical endpoints for dengue disease of differing severity categories are important for filling these gaps. They conclude that vascular leakage as manifested by clinical fluid accumulation, and hemoconcentration measured by hematocrit 40%, are important manifestations that are predictive of a shortened time towards progressing to severe dengue . Their findings imply the need for heightened surveillance and supple-ment other studies of clinical endpoints in dengue. The hallmark of severe dengue, particularly in the younger age group, is vascular permeability leading to plasma leakage, and subsequent circulatory shock and its consequences, which can be life threatening. The authors highlight the importance of other clinical manifestations such as persistent vomiting and mucosal bleeding in predicting time to severe disease progression. Early recognition and close monitoring of these clinical manifestations, along with timely institution of appropriate management can spell the difference between therapeutic success and failure among children with dengue infection. Clinical diagnosis and assessment of severity of confirmed dengue infections in Vietnamese children: Is the world health organization classification system helpful? World Health Organization: Dengue: Guidelines for Diagnosis, Treatment, Prevention and Control (2nd edn). Multicentre prospective study on dengue classification in four Southeast Asian and three Latin American countries. Development of standard clinical endpoints for use in dengue interventional trials. Severe dengue categories as research endpoints-Results from a prospective observational study in hospitalised dengue patients. Yes, the pendulum has swung from the era of undernutrition from 1960s-80s to the era of plenty, leading to over-nutrition from late 90s till the present. The healthcare systems are now focusing on the burden of obesity in childhood because of its long term consequences of non-communicable diseases in adulthood . However, surveillance for undernutrition is imperative as part of the life cycle approach to ensure optimum health at birth and later in life. The lower and the higher cut-off indicators on this chart were found appropriate for preliminary screening of a large number of children and adolescents in the community setting [9,10]. The validity of anthropometric data as a proxy for body fat identifies children at risk and correlates better with measures of body fat mass . Over the years, there has been a lack of consensus on the various cut-points or definitions used to classify obesity and overweight in children and adolescents. They also observed that the tool may wrongly categorize children at extreme ends of height for age. However, larger studies with a bigger sample size are required for validation and generalization of the tool. Efforts to decrease the existing nutritional scenario of dual burden of undernutrition alongside emerging over nutrition should be a top priority. The present narrative shows that overweight and obesity rates in children and adolescents are increasing among the higher socioeconomic groups and in the lower income groups where underweight still remains a major concern. No country can aim to attain economic and social development goals without addressing the issue of malnutrition. This suggests the need for a balanced and sensitive approach addressing economic and nutrition transitions to effectively tackle this double burden paradox in India. Since the comorbidities of undernutrition, low birth weight, and overweight/obesity with associated noncommunicable diseases co-exist in India, it is important to integrate nutritional concerns in developmental policies. A robust quality assured anonymized data collection and analysis system can provide national and local data that would inform the planning and evaluation of intervention programs. The burden of child and maternal malnutrition and trends in its indicators in the states of India: the Global Burden of Disease Study 1990-2017 [published correction appears in Lancet Child Adolesc Health. Prevalence of Obesity and Overweight Among School Children Aged 8-18 Years in Rajkot, Gujarat. Correspondence to: Dr Priya Sreenivasan, Associate Professor of Pediatrics, Government Medical College, Thiruvananthapuram, Kerala, India. Participants: 350 children aged 1 mo-12 y with serologically confirmed dengue without co-morbidities/co-infections; consecutive sampling. Disease progression, time of onset of each warning sign, hematocrit, and platelet counts were recorded daily till discharge/ death. Time to event analysis with Log Rank test, Kaplan Meier plots and Cox Proportional Hazards Model was done. Results: Among 350 children followed up completely till discharge/death, 90 developed severe dengue (event) while 260 did not (censored). Study results have implications in policy making and practice guidelines to triage children attending a health care facility with or without warning signs. Dengue is dynamic with febrile phase, critical phase (appearance of warning signs at/around defervescence mark onset of capillary leak) and convalescent phase . Potentially lethal severe dengue can manifest as shock, severe bleed or severe organ impairment in the critical phase or in the febrile phase without preceding warning signs . Close monitoring and timely initiation of intravenous fluids in the presence of any warning signs remain the only effective treatment modality in dengue . Severe dengue manifests as mostly shock in children and as severe bleeding and organ impairment in adults . Dynamicity of illness can be captured by taking into consideration the time to time variations in clinical and laboratory variables . The present study aimed to identify warning signs which can predict time taken for progression to severe dengue in children admitted to a tertiary care center. Close monitoring was done to note the time of onset of warning signs and severe dengue if any and need for administration of intravenous fluids till discharge or death. Daily examination for clinical fluid accumulation, hepatomegaly, hematocrit and platelet count were done in all patients.