By X. Aila. Circleville Bible College.
It is often expressed as the annual entomological inoculation rate cheap kytril 1 mg amex, which is the average number of inoculations with malaria parasites received by one person in 1 year buy kytril online pills. The stage of development of malaria parasites growing within host red blood cells from the ring stage to just before nuclear division effective 2 mg kytril. Symptomatic malaria parasitaemia with no signs of severity and/or evidence of vital organ dysfunction. Number of potential new infections that the population of a given anopheline mosquito vector would distribute per malaria case per day at a given place and time. Core principles The following core principles were used by the Guidelines Development Group that drew up these Guidelines. Early diagnosis and prompt, effective treatment of malaria Uncomplicated falciparum malaria can progress rapidly to severe forms of the disease, especially in people with no or low immunity, and severe falciparum malaria is almost always fatal without treatment. Therefore, programmes should ensure access to early diagnosis and prompt, effective treatment within 24–48 h of the onset of malaria symptoms. Rational use of antimalarial agents To reduce the spread of drug resistance, limit unnecessary use of antimalarial drugs and better identify other febrile illnesses in the context of changing malaria epidemiology, antimalarial medicines should be administered only to patients who truly have malaria. Combination therapy Preventing or delaying resistance is essential for the success of both national and global strategies for control and eventual elimination of malaria. To help protect current and future antimalarial medicines, all episodes of malaria should be treated with at least two effective antimalarial medicines with different mechanisms of action (combination therapy). Appropriate weight-based dosing To prolong their useful therapeutic life and ensure that all patients have an equal chance of being cured, the quality of antimalarial drugs must be ensured and antimalarial drugs must be given at optimal dosages. Treatment should maximize the likelihood of rapid clinical and parasitological cure and minimize transmission from the treated infection. To achieve this, dosage regimens should be based on the patient’s weight and should provide effective concentrations of antimalarial drugs for a suffcient time to eliminate the infection in all target populations. Strong recommendation, high-quality evidence Revised dose recommendation for dihydroartemisinin + piperaquine in young children Children < 25kg treated with dihydroartemisinin + piperaquine should receive a minimum of 2. Strong recommendation based on pharmacokinetic modelling Reducing the transmissibility of treated P. Strong recommendation Infants less than 5kg body weight Treat infants weighing < 5 kg with uncomplicated P. Strong recommendation, high-quality evidence In areas with chloroquine-resistant infections, treat adults and children with uncomplicated P. Conditional recommendation, moderate-quality evidence Treating severe malaria Treat adults and children with severe malaria (including infants, pregnant women in all trimesters and lactating women) with intravenous or intramuscular artesunate for at least 24 h and until they can tolerate oral medication. Strong recommendation, high-quality evidence Revised dose recommendation for parenteral artesunate in young children Children weighing < 20 kg should receive a higher dose of artesunate (3 mg/kg bw per dose) than larger children and adults (2. Strong recommendation based on pharmacokinetic modelling Parenteral alternatives where artesunate is not available If artesunate is not available, use artemether in preference to quinine for treating children and adults with severe malaria. Where intramuscular artesunate is not available use intramuscular artemether or, if that is not available, use intramuscular quinine. Strong recommendation, moderate-quality evidence Where intramuscular injection of artesunate is not available, treat children < 6 years with a single rectal dose (10mg/kg bw) of artesunate, and refer immediately to an appropriate facility for further care. Strong recommendation, high-quality evidence 12 Antimalarial drug quality National drug and regulatory authorities should ensure that the antimalarial medicines provided in both the public and the private sectors are of acceptable quality, through regulation, inspection and law enforcement. Good practice statement When possible, use: • fxed-dose combinations rather than co-blistered or loose, single-agent formulations; and • for young children and infants, paediatric formulations, with a preference for solid formulations (e. Malaria control requires an integrated approach, including prevention (primarily vector control) and prompt treatment with effective antimalarial agents. Since publication of the frst edition of the Guidelines for the treatment of malaria in 2006 and the second edition in 2010, all countries in which P. This has contributed substantially to reductions in global morbidity and mortality from malaria. The treatment recommendations in this edition of the Guidelines have a frm evidence base for most antimalarial drugs, but, inevitably, there are still information gaps. The Guidelines will therefore remain under regular review, with updates every 2 years or more frequently as new evidence becomes available. The treatment recommendations in the main document are brief; for those who wish to study the evidence base in more detail, a series of annexes is provided, with references to the appropriate sections of the main document. No guidance is given in this edition on the use of antimalarial agents to prevent malaria in people travelling from non-endemic settings to areas of malaria transmission. Other groups that may fnd them useful include health professionals (doctors, nurses and paramedical offcers) and public health and policy specialists working in hospitals, research institutions, medical schools, non-governmental organizations and agencies that are partners in health or malaria control, the pharmaceutical industry and primary health-care services. They also used raw data from the WorldWide Antimalarial Resistance Network, a repository of clinical and laboratory data on pharmacokinetics and dosing simulations in individual patients, including measurements using validated assays of concentrations of antimalarial medicines in plasma or whole blood. The data came either from peer-reviewed publications or were submitted to regulatory authorities for drug registration.
Management and treatment – When plague is suspected: take samples for cultures and antibiotic sensitivity testing and then treat immediately without waiting for the diagnosis to be confirmed buy 1mg kytril with mastercard. Their bedding generic 2mg kytril, clothing buy line kytril, sputum and excreta must be disinfected with a chlorinated solution. Observe elementary rules of hygiene (wash hands, wear hospital lab coats, gloves etc. Clinical features Diagnosis is difficult because of the broad spectrum of clinical manifestations. A distinction is usually made between the mild form (the most common, usually with a favourable outcome) and the severe form (multiple organ dysfunction syndrome). Other signs: conjunctival haemorrhage, hepatosplenomegaly, and multiple adenopathies. After a few days, acute hepatorenal manifestations with fever, jaundice, oligo-anuric renal failure; diffuse haemorrhagic syndrome (purpura, ecchymoses, epistaxis etc. It occurs in epidemic waves when conditions favourable to the transmission of body lice are met: cold climate/season, overcrowding and very poor sanitation (e. Clinical features – Relapsing fever is characterized by febrile episodes separated by afebrile periods of approximately 7 days (4 to 14 days). Laboratory The diagnosis is confirmed by detection of Borrelia in thick or thin blood films (Giemsa stain). Spirochetes are not found in the 194 Bacterial diseases peripheral blood during afebrile periods. In addition, the number of circulating spirochetes tends to decrease with each febrile episode. The clinical diagnosis is difficult, especially during the first episode: cases occur sporadically rather than in outbreaks; the tick bite is painless and usually unnoticed by the patient; symptoms are very similar to those of malaria, typhoid fever, leptospirosis, certain arbovirosis (yellow fever, dengue) or rickettsiosis, and meningitis. Antibiotic therapy can trigger a Jarisch-Herxheimer reaction with high fever, chills, fall in blood pressure and sometimes shock. It is recommended to monitor the patient for 2 hours after the first dose of antibiotic, for occurrence and management of severe Jarisch-Herxheimer reaction (symptomatic treatment of shock). Three main groups are distinguished: typhus group, spotted fever group and scrub typhus group. Laboratory Detection of specific IgM of each group by indirect immunofluorescence. In practice, clinical signs and the epidemiological context are sufficient to suggest the diagnosis and start treatment. Acetylsalicylic acid (aspirin) is contra- indicated due to 7 the risk of haemorrhage. However, the administration of a single dose should not, in theory, provoke adverse effects. However, the geographical distribution of borrelioses and rickettsioses may overlap, and thus a reaction may occur due to a possible co-infection (see Borreliosis). Group Typhus Spotted fever Scrub typhus Mediterranean Rocky Mountain Other Old-World Form Epidemic typhus Murine typhus Scrub typhus spotted fever spotted fever tick-borne fevers Pathogen R. The disease mainly affects children under 5 years of age and can be prevented by immunization. Prodromal or catarrhal phase (2 to 4 days) – High fever (39-40°C) with cough, coryza (nasal discharge) and/or conjunctivitis (red and watery eyes). This sign is specific of measles infection, but may be absent at the time of examination. Eruptive phase (4 to 6 days) – On average 3 days after the onset of symptoms: eruption of erythematous, non- pruritic maculopapules, which blanch with pressure. The rash begins on the forehead then spreads downward to the face, neck, trunk (2nd day), abdomen and lower limbs (3rd and 4th day). In the absence of complications, the fever disappears once the rash reaches the feet. In practice, a patient presenting with fever and erythematous maculopapular rash and at least one of the following signs: cough or coryza or conjunctivitis, is a clinical case of measles. Treatment Supportive and preventive treatment – Treat fever: paracetamol (Fever, Chapter 1). Croup is considered benign or “moderate” if the stridor occurs when the child is agitated or crying, but disappears when the child is calm. The child should be monitored during this period, however, because his general and respiratory status can deteriorate rapidly. Croup is severe when the stridor persists at rest or is associated with signs of respiratory distress. Human-to- human transmission is direct (faecal-oral) or indirect (ingestion of food and water contaminated by stool). In non- endemic areas, where vaccination coverage is low, young adults are most commonly affected.
Psychosis associated with substance abuse and mood disorders with psychotic features may mimic schizophrenia buy discount kytril 2 mg line. Treatment objectives • To abolish symptoms and restore functioning to the maximum level possible • To reduce the chances of recurrence Non-pharmacological treatment • Supportive psychotherapy • Rehabilitation Pharmacological treatment (Evidence rating: A) Antipsychotic drugs are the mainstay of treatment cheap kytril 2mg on-line. This refers to a condition in which patients experience mood swings between the two extremes of mood disorder depression and mania order genuine kytril on line. It is important to note that the affected patient usually presents with one predominant mood state at a time, either Depression or Mania. A single manic episode and a history of depression qualify for classification as Bipolar Disorder. A current episode of depression without a past manic episode or with a past history of depression is not diagnostic of Bipolar Disorder. Occasionally, substance (cocaine, marijuana, amphetamine) abuse may precipitate the condition. The benzodiazepines are withdrawn as soon as the patient is calm, but this should be done by slowly tapering the dose. The antipsychotics are continued at a dose just enough to control the symptoms and should be continued for at least 3-4 weeks. The greatest problem is the recognition and diagnosis of alcoholism since affected individuals are often in denial of their problem. They under- declare the amount and frequency of alcohol consumption and usually appear in hospital only with complications. The coexistence of other psychiatric illnesses like Depression with alcoholism is common. Alternative treatment • Chlordiazepoxide, oral, Day 1: 50 mg 4 hourly Day 2: 50 mg 6 hourly Day 3: 25 mg 4 hourly Day 4: 25 mg 6 hourly If there is a history of concomitant benzodiazepine abuse, this may not be effective therefore consult a psychiatrist. Without treatment, symptoms subside within a week, but may occasionally last longer. It consists of sudden generalised seizures and occurs mostly in chronic alcoholics. It consists of vivid unpleasant auditory hallucinations occurring in the presence of a clear sensorium. Without good supportive care and adequate treatment, Delirium Tremens is associated with significant mortality. Visual hallucinations are frequently of small objects or frightening animals on walls etc. Some patients have a mixture of anxiety and depressive symptoms, but pure states exist. Due of the similarity of symptoms, it may be difficult to differentiate an anxiety state from a minor depressive illness. It may be worthwhile to exclude any underlying physical disease especially hyperthyroidism, cardiac disease or hypertension. Although there are various forms of anxiety disorders (generalised anxiety disorder, panic disorder, phobias, obsessive compulsive disorder, acute stress disorder, post traumatic stress disorder), the commonest seen in general practice are generalised anxiety disorders and panic disorders. During attacks 4 or more of the symptoms listed below develop abruptly and reach a peak within 10 minutes. Panic disorders are accompanied by persistent concern about having another attack or worrying about implications of having an attack. Medications are required to treat panic disorders only if the attacks occur frequently enough to cause distress. A more superficial infection is termed folliculitis and a group of boils in an area is termed a carbuncle. Patients with recurrent boils or carbuncles should be screened for diabetes mellitus and/or immunodeficiency. It may be associated with conditions such as scabies, eczema, lice infestation and herpes simplex infection. Its prevention involves good hygiene, regular hand-washing, trimming of fingernails to reduce breaking of the skin through scratching, and discouraging the sharing of towels and clothing. Pharmacological treatment (Evidence rating: B) Mild and moderate cases: • Flucloxacillin, oral, Adults 250-500 mg 6 hourly for 7 days Children 5-12 years; 250 mg 6 hourly for 7 days 1-5 years; 125 mg 6 hourly for 7 days < 1 year; 62. Usually it follows an infected wound or prick by a pin, nail, thorn, insect bite or cracks between the toes. While it is known that this ulcer is caused by a bacterium, the mode of transmission remains unclear. No definite efficacious medication for the disease exists, even though a number of candidate drugs are at clinical drug trial stage. For this to be achieved it is important to educate the public on early recognition and early reporting of the disease. Also refer cases for treatment with selected combinations of anti-tuberculous medications. Most people affected are children under 15 years of age but adults are not exempt.
Assertive outreach: An effective strategy for engaging homeless persons with substance use disorders into treatment purchase kytril 2mg mastercard. The impact of syringe and needle exchange programs on drug use rates in the United States buy cheap kytril line. Evidence for the effectiveness of sterile injecting equipment provision in preventing hepatitis C and human immunodefciency virus transmission among injecting drug users: A review of reviews order 2 mg kytril overnight delivery. Preventing fatal overdoses: A systematic review of the effectiveness of take-home naloxone. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: Interrupted time series analysis. Expanded access to naloxone: Options for critical response to the epidemic of opioid overdose mortality. Factors affecting detoxifcation readmission: Analysis of public sector data from three states. A performance measure for continuity of care after detoxifcation: Relationship with outcomes. Principles of adolescent substance use disorder treatment: A research-based guide. An improved diagnostic instrument for substance abuse patients: The Addiction Severity Index. The relative effectiveness of women-only and mixed-gender treatment for substance-abusing women. A randomized experimental study of gender-responsive substance abuse treatment for women in prison. Guiding principles and elements of recovery-oriented systems of care: What do we know from the research? Disparities in completion of substance abuse treatment between and within racial and ethnic groups. Disparities in Latino substance use, service use, and treatment: Implications for culturally and evidence-based interventions under health care reform. Removing obstacles to eliminating racial and ethnic disparities in behavioral health care. Blacks and Hispanics are less likely than whites to complete addiction treatment, largely due to socioeconomic factors. Use of pharmacotherapies in the treatment of alcohol use disorders and opioid dependence in primary care. Opioid addiction and abuse in primary care practice: a comparison of methadone and buprenorphine as treatment options. Reducing mortality of people who use opioids through medication assisted treatment for opioid dependence. Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, 1995- 2009. National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction. Methadone maintenance vs 180-day psychosocially enriched detoxifcation for treatment of opioid dependence: A randomized controlled trial. Methadone and buprenorphine for the management of opioid dependence: A systematic review and economic evaluation. Opioid maintenance treatment as a harm reduction tool for opioid-dependent individuals in New York City: The need to expand access to buprenorphine/naloxone in marginalized populations. Prior experience with non-prescribed buprenorphine: Role in treatment entry and retention. Treatment outcomes in opioid dependent patients with different buprenorphine/naloxone induction dosing patterns and trajectories. Clinical guidelines for the use of buprenorphine in the treatment of opioid addiction. An introduction to extended-release injectable naltrexone for the treatment of people with opioid dependence. Clinical use of extended- release injectable naltrexone in the treatment of opioid use disorder: A brief guide. Substance Abuse and Mental Health Services Administration, & National Institute on Alcohol Abuse and Alcoholism. Pharmacological means of reducing human drug dependence: A selective and narrative review of the clinical literature. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: A systematic review and meta-analysis. Meta- analysis of naltrexone and acamprosate for treating alcohol use disorders: When are these medications most helpful? Testing the effectiveness of cognitive-behavioral treatment for substance abuse in a community setting: Within treatment and posttreatment fndings. Cognitive-behavioral therapy for comorbid bipolar and substance use disorders: A systematic review of controlled trials. A randomized factorial trial of disulfram and contingency management to enhance cognitive behavioral therapy for cocaine dependence.
Infections extending to adjacent anatomical structures (acute dento-alveolar abscess) Local spreading of an acute dental abscess into the surrounding bone and tissue purchase kytril 1mg overnight delivery. If there is no improvement within 48 to 72 hours after the dental procedure cheap kytril 2mg on-line, do not change antibiotic purchase discount kytril, but start a new procedure on the tooth. Infections extending into the cervico-facial tissues – Extremely serious cellulitis, with rapidly spreading cervical or facial tissue necrosis and signs of septicaemia. Anxiety is a common feature in depression, post-traumatic stress disorder and psychosis). However, before prescribing haloperidol, re-evaluate for possible depression or post-traumatic stress disorder (see Post-traumatic stress disorder and Depression). Continue for 2 to 3 months after symptoms resolve then, stop gradually (over 3 to 4 weeks) while monitoring the patient for recurrence of symptoms. Help him focus on his breathing so that it becomes calmer and more regular, with three-phase breathing cycles: inhalation (count to three), exhalation (count to three), pause (count to three), etc. If the insomnia is related to the use of alcohol, drugs or a medicationa, management depends on the substance responsible. Insomnia is a common feature in depression, post-traumatic stress disorder and anxiety disorders. Agitation is also common in acute intoxication (alcohol/drugs) and withdrawal syndrome (e. Management Clinical evaluation is best performed in pairs, in a calm setting, with or without the person’s family/friends, depending on the situation. However, its use should be view as a temporary measure, always in combination with sedation and close medical supervision. Determine whether or not the patient is confused; look for an underlying cause, e. If the agitation is associated with anxiety, see Anxiety; if associated with psychotic disorders, see Psychotic disorders. Alcoholic patients can experience withdrawal symptoms within 6 to 24 hours after they stop drinking. In the early phase (pre-delirium tremens), the manifestations include irritability, a general feeling of malaise, profuse sweating and shaking. Withdrawal syndrome should be taken into consideration in patients who are hospitalised and therefore forced to stop drinking abruptly. At a more advanced stage (delirium tremens), agitation is accompanied by fever, mental confusion and visual hallucinations (zoopsia). The doses and duration of the treatment are adapted according to 11 the clinical progress. These symptoms develop rapidly (hours or days), and often fluctuate during the course of the day. Agitation, delusions, behavioural disorders and hallucinations (often visual) may complicate the picture. Also consider treatment adverse effects (corticosteroids, opioid analgesics, psychotropic drugs, etc. Immediate, transitory disorders (prostration, disorientation, fleeing, automatic behaviours, etc. The patient may develop somatic symptoms such as hypertension, sweating, shaking, tachycardia, headache, etc. Re-experiencing is highly distressing and causes disorders that may worsen over time; people isolate themselves, behave differently, stop fulfilling their family/social obligations, and experience diffuse pain and mental exhaustion. It is important to reassure the patient that his symptoms are a comprehensible response to a very abnormal event. Avoid over active explorations of the patient’s emotions: leave it to the patient to decide how far he wants to go. Associated symptoms (anxiety or insomnia), if persistent, can be relieved by symptomatic a 11 treatment (diazepam) for no more than two weeks. The classic diagnostic criteria for a major depressive episode are: – Pervasive sadness and/or a lack of interest or pleasure in activities normally found pleasurable And – At least four of the following signs: • Significant loss of appetite or weight • Insomnia, especially early waking (or, more rarely, hypersomnia) • Psychomotor agitation or retardation • Significant fatigue, making it difficult to carry out daily tasks • Diminished ability to make decisions or concentrate • Feeling of guilt or worthlessness, loss of self-confidence or self-esteem • Feeling of despair • Thoughts of death, suicidal ideation or attempt The features of depression can vary, however, from one culture to anothera. For example, the depressed patient may express multiple somatic complaints rather than psychological distress. Depression may also manifest itself as an acute psychotic disorder in a given cultural context. Management When faced with symptoms of depression, consider an underlying organic cause (e. These symptoms should not be neglected, especially as they have a negative impact on adherence to treatment.
To optimize the benefts of effective treatment buy on line kytril, wide dissemination of national treatment guidelines proven 2mg kytril, clear recommendations purchase kytril canada, appropriate information, education and communication materials, monitoring of the deployment process, access and coverage, and provision of adequately packaged antimalarial drugs are needed. Community case management should be integrated into community management of childhood illnesses, which ensures coverage of priority childhood illnesses outside of health facilities. Clear guidelines in the language understood by local users, posters, wall charts, educational videos and other teaching materials, public awareness campaigns, education and provision of information materials to shopkeepers and other dispensers can improve the understanding of malaria. They will increase the likelihood of better prescribing and adherence, appropriate referral and unnecessary use of antimalarial medicines. Prescribers, shopkeepers and vendors should therefore give clear, comprehensible explanations of how to use the medicines. Effectiveness of artemisinin-based combination therapy used in the context of home management of malaria: a report from three study sites in sub-Saharan Africa. This method ensures a transparent link between the evidence and the recommendations. The Technical Guidelines Development Group, co-chaired by Professor Fred Binka and Professor Nick White (other participants are listed below), organized a technical consultation on preparation of the third edition of the Guidelines. A review of data on pharmacokinetics and pharmacodynamics was considered necessary to support dose recommendations, and a subgroup was formed for this purpose. After the scoping meeting, the Cochrane Infectious Diseases Group at the Liverpool School of Tropical Medicine in Liverpool, England, was commissioned to undertake systematic reviews and to assess the quality of the evidence for each priority question. When insuffcient evidence was available from randomized trials, published reviews of non-randomized studies were considered. The data had either been included in peer-reviewed publications or been submitted to regulatory authorities for drug registration. Population pharmacokinetics models were constructed, and the plasma or whole blood concentration profles of antimalarial medicines were simulated (typically 1000 times) for different weight categories. At various times during preparation of the guidelines, sections of the document or recommendations were reviewed by external experts and users who were not members of the group; these external peer reviewers are listed below. Treatment recommendations were agreed by consensus, supported by systematic reviews and review of information on pharmacokinetics and pharmacodynamics. Areas of disagreement were discussed extensively to reach consensus; voting was not required. Barnes, Division of Clinical Pharmacology, University of Cape Town, South Africa Professor F. Binka, (co-Chair), University of Health and Allied Sciences, Ho, Volta Region, Ghana Professor A. Bjorkman, Division of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden Professor M. Garner, Liverpool School of Tropical Medicine, Liverpool, United Kingdom Professor O. Gaye, Service de Parasitologie, Faculté de Médicine, Université Cheikh Anta Diop, Dakar-Fann, Senegal Dr S. Juma, Kenya Medical Research Institute, Centre for Clinical Research, Nairobi, Kenya Dr A. McCarthy, Tropical Medicine and International Health Clinic, Division of Infectious Diseases, Ottawa Hospital General Campus, Ottawa, Canada Professor O. Mokuolu, Department of Paediatrics, University of Ilorin Teaching Hospital, Ilorin, Nigeria Dr D. Sinclair, International Health Group, Liverpool School of Tropical Medicine, Liverpool, United Kingdom Dr L. Tjitra, National Institute of Health and Development, Ministry of Health, Jakarta, Indonesia 126 Dr N. White (co-Chair), Faculty of Tropical Medicine, Mahidol University, A Bangkok, Thailand 1 Members of the sub-group on dose recommendations Professor K. Barnes, (co-chair), Division of Clinical Pharmacology, University of Cape Town, South Africa Professor F. Juma, Kenya Medical Research Institute, Centre for Clinical Research, Nairobi, Kenya Professor O. Mokuolu, Department of Paediatrics, University of Ilorin Teaching Hospital, Ilorin, Nigeria Dr S. Tarning, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand Dr D. Terlouw, Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi Professor N. White (co-Chair), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand Guideline Steering Group Dr A.
Units – Heparin and Insulin • The purity of drugs such as insulin and heparin from animal or biosynthetic sources varies discount kytril 2 mg line. These medicines are usually liquids that are for oral or parenteral administration order kytril australia, but also include those for topical use buy discount kytril on-line. The aim of this chapter is to explain the various ways in which drug strengths can be stated. Percentage concentration can be defined as the amount of drug in 100 parts of the product. The most common method you will come across is the percentage concentration w/v (weight in volume). This is used when a solid is dissolved in a liquid and means the number of grams dissolved in 100mL: % w/v = number of grams in 100mL (Thus 5% w/v means 5g in 100mL. This is used when a liquid is mixed or diluted with another liquid, and means the number of millilitres (mL) in 100mL: % v/v = number of mL in 100mL (Thus 5% v/v means 5mL in 100mL. In our earlier example of 5% w/v, there are 5g in 100mL irrespective of the size of the container. For example, glucose 5% infusion means that there are 5g of glucose dissolved in each 100mL of fluid and this will remain the same if it is a 500mL bag or a 1 litre bag. To find the total amount of drug present in a bottle or infusion bag, you must take into account the size or volume of the bottle or infusion bag. So to find out the total amount present, multiply how much is in 1mL by the volume you’ve got (200mL): 8. A simple formula can be devised based upon the formula seen earlier: base amount = ×per cent 100 This can be re-written as: percentage total amount (g) = × total volume (mL) 100 Therefore in this example: Percentage = 8. Question 2 How many grams of potassium, sodium and glucose are there in a litre infusion of potassium 0. Question 3 How many grams of sodium chloride are there in a 500mL infusion of sodium chloride 0. For oral liquids, it is usually expressed as the number of milligrams in a standard 5mL spoonful, e. For oral doses that are less than 5mL an oral syringe would be used (see the section ‘Administration of medicines’ in Chapter 9 ‘Action and administration of medicines’, page xx). For injections, it is usually expressed as the number of milligrams per volume of the ampoule (1mL, 2mL, 5mL, 10mL and 20mL), e. Only mg/mL will be considered here, but the principles learnt here can be applied to other concentrations or strengths, e. Sometimes it may be useful to convert percentage concentrations to mg/mL concentrations. If you know the percentage concentration, an easy way of finding the strength in mg/mL is by simply multiplying the percentage by 10. Once again, if we use our original lidocaine (lignocaine) as an example: You have lidocaine (lignocaine) 2mg/mL. It usually refers to a solid dissolved in a liquid and, by agreed convention, the weight is expressed in grams and the volume in millilitres. For example: ‘1 in 1,000’ means 1g in 1,000mL ‘1 in 10,000’ means 1g in 10,000mL Therefore it can be seen that 1 in 10,000 is weaker than 1 in 1,000. The drug most commonly expressed this way is adrenaline/epinephrine: Adrenaline/epinephrine 1 in 1,000 which is equal to 1mg in 1mL Adrenaline/epinephrine 1 in 10,000 which is equal to 1mg in 10mL An easy way to remember the above is to cancel out the three zeros that appear after the comma, i. Adrenaline/epinephrine 1 in 1,000 – cancel out the three zeros after the comma: 1,000/ / /, to give: 1 in 1 which can be written as: 1mg in 1mL Similarly, for adrenaline/epinephrine 1 in 10,000 – cancel out the three zeros after the comma: 10,000/// to give: 1 in 10, which can be written as 1mg in 10mL. Just as per cent means parts of a hundred, so parts per million or ppm means parts of a million. It usually refers to a solid dissolved in a liquid but, as with percentage concentrations, it can also be used for two solids or two liquids mixed together. Once again, by agreed convention: 1 ppm means 1g in 1,000,000mL or 1mg in 1 litre (1,000mL) In terms of percentage, 1 ppm equals 0. Other equivalents include: One part per million is one second in 12 days of your life! Haz-Tabs®) are measured in terms of parts per million, such as 1,000 ppm available chlorine. Question 12 It is recommended that children should have fluoride supplements for their teeth if the fluoride content of drinking water is 0. Such large molecules are difficult to purify and so, rather than use a weight, it is more accurate to use the biological activity of the drug, which is expressed in units. The calculation of doses and their translation into suitable dosage forms are similar to the calculations elsewhere in this chapter. Infusions are usually given over 24 hours and the dose is adjusted according to laboratory results. As a result of this cumulative administration error the patient died from a brain haemorrhage which, in the opinion of the pathologist, was due to the overdose of tinzaparin. It was the prescriber’s intention that the patient should receive 9,000 units of tinzaparin each day, but this information was not written on the prescription.