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Documentation and reporting Pediculosis Treatment Purpose • To prevent transmission of some arthropod born diseases • To make patient comfortable Definition Pediculosis: infestation with lice Lice: • Are small purchase 400 mg levitra plus with amex, grayish white buy levitra plus amex, parasitic insects that infest mammals • Are of three common kinds: ¾ Pediculose capitis: is found on the scalp and tends to stay hidden in the hairs ¾ Pediculose pubis: stay in pubic hair ¾ Pediculose corporis: tends to cling to clothing order levitra plus 400 mg mastercard, suck blood from the person and lay their eggs the clothing suspect their presence in the clothing if: a order levitra plus 400mg online. There are hemorrhagic spots in the skin where the lice have sucked blood Head and body lice lay their eggs on the hairs then eggs look like oval particles, similar to dandruff, clinging to the hair. Kerosene Oil mixed with equal parts of sweet oil • Destroys both adult lice and eggs of nits • From aesthetic point of view, kerosene causes foul smell and create discomfort to patient and the attendant Guidelines for Applying Pediculicides Hair: • Apply pediculicide shampoo to dry hair until hair is thoroughly saturated and work shampoo in to a lather • Allow product to remain on hair for stated period (varies with products) • Pin hair and allow to dry • Use a fine toothed comb to remove death lice and nits (comb should not be shared by other family members) • Repeat it in 8-10 days to remove any hatched nits • Apply pediculious lotion (or cream) to affected areas • Bath after 12 hrs and put on clean clothes 3. Oil of Sassafras • Is a kind of scented bark oil • Only destroy lice not nits • For complete elimination, the oil should be massaged again after 10 days when the nits hatch • Is used daily for a week with equal parts of Luke warm H2O then it should be repeated after a week 4. Gcmmaxine (Gamma Bengenhexa Chloride) Basic Nursing Art 51 • Emphasize the need for treatment of sexual partner • After complete bathing wash linen available as a cream, lotion, and a shampoo • 1. However, many peoples, because of weakness, immobility and/or one or both upper extremities are unable to feed themselves all or parts of the meal. Therefore, the nurse must be knowledgeable, sensitive and skillful in carrying out feeding procedures. Purpose • To be sure the pt receives adequate nutrition • To promote the pt well-beings Procedure 1. Prepare pt units • Remove all unsightly equipments; remove solid linens and arranging bedside tables. Basic Nursing Art 52 • Control unpleasant odors in the room by refreshing the room. Lab, radiologic examination or surgery) • Assess any cultural or religious limitations, specific likes or dislikes. Feed the patient • Place the food tray in such a way that the patient can see the food. Comfort patient • Assist hand washing and oral care Basic Nursing Art 53 • Offer bedpan and commodes, of indicated • Comfort patient, provide quite environment so that the pt may relax after meal, which also promote good digestion. Objective Symptoms (signs): Are symptoms, which could be seen by the health personnel? Charting Definition: it is a written record of history, examination, tests, diagnosis, and prognosis response to therapy Basic Nursing Art 56 Purpose of Patients Chart a. For diagnosis or treatment of a patient while in the hospital (find after discharge) if patient returns for treatment in the future time b. For serving an information in the education of health personnel (medical students, interns , nurses, dietitians, etc) e. For promoting public health General Rules for Charting • Spelling Make certain you spell correctly • Accuracy Records must be correct in all ways, be honest • Completeness No omission, avoid unnecessary words or statement • Exactness Do not use a word you are not sure of • Objective information Record what you see avoid saying (condition better) • Legibility Print/write plainly and distinctively as possible • Neatness No wrinkles, proper speaking of items Place all abbreviation, and at end of statement • Composition / arrangement Basic Nursing Art 57 Chart carefully consult if in doubt avoid using of chemical formulas • Sentences Need not be complete but must be clear, avoid repetition • Time of charting Specific time and date • Color of ink Black or blue (red for transfusion, days of surgery) It should be recorded on the graphic sheet All orders should be written and signed. Verbal or telephone orders should be taken only in emergency verbal orders should be written in the order sheet and signed on the next visit. Laboratory reports • Patients or relatives and friends of patients are not allowed to read the chart 4. Intake: all fluids that is taken in to the body through the mouth, n/g tube or parentrally b. When a client has a change in health status or reports symptoms such as chest pain or fainting 3. Age • Children’s temperature continue to be more labile than those of adults until puberty • Elderly people, particularly those > 75 are at risk of hypothermia • Normal body temperature of the newborn if taken orally is 37 0 C. Diurnal variations (circadian rhythms) • Body temperature varies through out the day • The point of highest body temperature is usually reached between 8:00 p. Exercise • Hard or strenuous exercise can increase body temperature to as high as 38. Hormones • In women progesterone secretion at the time of ovulation o raises body temperature by about 0. Stress • Stimulation of skin can increases the production of epinephrine and nor epinephrine – which increases metabolic activity and heat production. Environment • Extremes in temperature can affect a person’s temperature regulatory systems. A client who has fever is referred to as febrile; the one who has not is a febrile. Basic Nursing Art 60 0 0 0 Hypothermia: – body temperature between 34 c – 35 c, < 34 c is death Common Types of Fevers 1. Intermittent fever: the body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal temperature. Remittent fever: a wide range of temperature fluctuation (more than 0 2 c) occurs over the 24 hr period, all of which are above normal 3. Relapsing fever: short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature. Constant fever: the body temperature fluctuates minimally but always remains above normal Measuring Body Temperature There are Two Kinds of Body Temperature 1. Core Temperature • Is the Temperature of the deep tissues of the body, such as the cranium, thorax, abdominal cavity, and pelvic cavity • Remains relatively constant • Is the Temperature that we measure with thermometer 2. Surface Temperature: • The temperature of the skin, the subcutaneous tissue and fat Sites of Measure Temperature Most common are: • Oral • Rectal • Axillary • Tympanic membrane Thermometer: is an instrument used to measure body temperature Basic Nursing Art 61 Types 1. Rectal Temperature: Readings are considered to be more accurate, most reliable Contraindication • Rectal or perineal surgery; • Fecal impaction – the depth of the thermometer insertion may be insufficient; • Rectal infection; • Neonates –can cause rectal perforation and ulceration; 0 0 • Is > 0. Oral • Most accessible and convenient • The thermometer tip is placed beside the frenulum below the tongue • Is 0. Pulse It is a wave of blood created by contraction of the left ventricle of the heart. Stress: increases the sympathetic nerve stimulation – increases the rate and force of heart beat 8. Position changes: when a patient assumes a sitting or standing position blood usually pools in dependent vessels of the venous system. Temporal: is superior (above) and lateral to (away from the midline of) the eye 2. Carotid: at the side of the neck below tube of the ear (where the carotid artery runs between the trachea and the sternoclidiomastoid muscle) 3. Apical: at the apex of the heart: routinely used for infant and children < 3 yrs th th th 4. In adults – Left midclavicular line under the 4 , 5 , 6 intercostals space Basic Nursing Art 64 5. Brachial: at the inner aspect of the biceps muscle of the arm or medially in the antecubital space (elbow crease) 7. Radial: on the thumb side of the inner aspect of the wrist – readily available and routinely used 8. Pedal (Dorslais Pedis): palpated by feeling the dorsum (upper surface) of the foot on an imaginary line drawn from the middle of nd the ankle to the surface between the big and 2 toes Method Pulse: is commonly assessed by palpation (feeling) or auscultation (hearing) The middle 3 fingertips are used with moderate pressure for palpation of all pulses except apical; the most distal parts are more sensitive, Assess the Pulse for • Rate • Rhythm • Volume • Elasticity of the arterial wall Pulse Rate • Normal 60-100 b/min (80/min) • Tachycardia – excessively fast heart rate (>100/min) • Bradycardia < 60/min Pulse Rhythm • The pattern and interval between the beats, random, irregular beats – dysrythymia Basic Nursing Art 65 Pulse Volume: the force of blood with each beat • A normal pulse can be felt with moderate pressure of the fingers and can be obliterated with greater pressure. Hyperventilation: very deep, rapid respiration Hypoventilation: very shallow respiration Two Types of Breathing 1. Costal (thoracic) • Involves the external muscles and other accessory muscles (sternoclodio mastoid) • Observed by the movement of the chest up ward and down ward 2. Diaphragmatic (abdominal) • Involves the contraction and relaxation of the diaphragm, observed by the movement of abdomen. Basic Nursing Art 66 Assessment • The client should be at rest • Assessed by watching the movement of the chest or abdomen. Rhythm: is the regularity of expiration and inspiration Normal breathing is automatic & effortless. Systolic pressure: is the pressure of the blood as a result of contraction of the ventricle (is the pressure of the blood at the height of the blood wave); 2. Pulse pressure: is the difference between the systolic and diastolic pressure Blood pressure is measured in mm Hg and recorded as fraction. Conditions Affecting Blood Pressure Fever Increase Stress " Arteriosclerosis " Obesity " Hemorrhage Decrease Low hematocrit " External heat " Exposure to cold Increase Sites for Measuring Blood Pressure 1. Leg using posterior tibial or dorsal pedis Methods of Measuring Blood Pressure Blood pressure can be assessed directly or indirectly 1. Direct (invasive monitoring) measurement involves the insertion of catheter in to the brachial, radial, or femoral artery. The flush methods Basic Nursing Art 68 The auscultatory method is the commonest method used in health activities. Phase 1: The pressure level at which the 1st joint clear tapping sound is heard, these sounds gradually become more intense. Prepare and position the patient appropriately • Make sure that the client has not smoked or ingested caffeine, with in 30 minutes prior to measurement. The arm should be slightly flexed with the palm of the hand facing up and the fore arm supported at heart level • Expose the upper arm 2.

Primary Vesicles As the anterior end of the neural tube starts to develop into the brain order 400mg levitra plus overnight delivery, it undergoes a couple of enlargements buy levitra plus online pills; the result is the production of sac-like vesicles 400mg levitra plus visa. These vesicles are given names that are based on Greek words purchase 400mg levitra plus otc, the main root word being enkephalon, which means “brain” (en- = “inside”; kephalon = “head”). The prefix to each generally corresponds to its position along the length of the developing nervous system. The prosencephalon (pros- = “in front”) is the forward-most vesicle, and the term can be loosely translated to mean forebrain. The first part of this word is also the root of the word rhombus, which is a geometrical figure with four sides of equal length (a square is a rhombus with 90° angles). Whereas prosencephalon and mesencephalon translate into the English words forebrain and midbrain, there is not a word for “four-sided-figure-brain. One way of thinking about how the brain is arranged is to use these three regions—forebrain, midbrain, and hindbrain—which are based on the primary vesicle stage of development (Figure 13. Secondary Vesicles The brain continues to develop, and the vesicles differentiate further (see Figure 13. The diencephalon gives rise to several adult structures; two that will be important are the thalamus and the hypothalamus. In the embryonic diencephalon, a structure known as the eye cup develops, which will eventually become the retina, the nervous tissue of the eye called the retina. The midbrain is an established region of the brain at the primary vesicle stage of development and remains that way. Dividing the brain into forebrain, midbrain, and hindbrain is useful in considering its developmental pattern, but the midbrain is a small proportion of the entire brain, relatively speaking. The metencephalon corresponds to the adult structure known as the pons and also gives rise to the cerebellum. The cerebellum (from the Latin meaning “little brain”) accounts for about 10 percent of the mass of the brain and is an important structure in itself. The most significant connection between the cerebellum and the rest of the brain is at the pons, because the pons and cerebellum develop out of the same vesicle. The structures that come from the mesencephalon and rhombencephalon, except for the cerebellum, are collectively considered the brain stem, 552 Chapter 13 | Anatomy of the Nervous System which specifically includes the midbrain, pons, and medulla. As the anterior end of the neural tube develops, it enlarges into the primary vesicles that establish the forebrain, midbrain, and hindbrain. Those structures continue to develop throughout the rest of embryonic development and into adolescence. How would you describe the difference in the relative sizes of the three regions of the brain when comparing the early (25th embryonic day) brain and the adult brain? Spinal Cord Development While the brain is developing from the anterior neural tube, the spinal cord is developing from the posterior neural tube. The neural tube is defined in terms of its anterior versus posterior portions, but it also has a dorsal–ventral dimension. As the neural tube separates from the rest of the ectoderm, the side closest to the surface is dorsal, and the deeper side is ventral. As the spinal cord develops, the cells making up the wall of the neural tube proliferate and differentiate into the neurons and glia of the spinal cord. The dorsal tissues will be associated with sensory functions, and the ventral tissues will be associated with motor functions. Relating Embryonic Development to the Adult Brain Embryonic development can help in understanding the structure of the adult brain because it establishes a framework on which more complex structures can be built. First, the neural tube establishes the anterior–posterior dimension of the nervous system, which is called the neuraxis. Humans (and other primates, to some degree) make this complicated by standing up and walking on two legs. The anterior–posterior dimension of the neuraxis overlays the superior–inferior dimension of the body. Because of this, the neuraxis starts in an inferior position—the end of the spinal cord—and ends in an anterior position, the front of the cerebrum. Without the flexure in the brain stem, and at the top of the neck, that animal would be looking straight up instead of straight in front (Figure 13. Humans, as two-legged animals, have a bend in the neuraxis between the brain stem and the diencephalon, along with a bend in the neck, so that the eyes and the face are oriented forward. In summary, the primary vesicles help to establish the basic regions of the nervous system: forebrain, midbrain, and hindbrain. The secondary vesicles go on to establish the major regions of the adult nervous system that will be followed in this text. The diencephalon continues to be referred to by this Greek name, because there is no better term for it (dia- = “through”). The diencephalon is between the cerebrum and the rest of the nervous system and can be described as the region through which all projections have to pass between the cerebrum and everything else. The brain stem includes the midbrain, pons, and medulla, which correspond to the mesencephalon, metencephalon, and myelencephalon. One other benefit of considering embryonic development is that certain connections are more obvious because of how these adult structures are related. The eyes are just inferior to the anterior-most part of the cerebrum, but the optic nerve extends back to the thalamus as the optic tract, with branches into a region of the hypothalamus. There is also a connection of the optic tract to the midbrain, but the mesencephalon is adjacent to the diencephalon, so that is not difficult to imagine. The cerebellum originates out of the metencephalon, and its largest white matter connection is to the pons, also from the metencephalon. There are connections between the cerebellum and both the medulla and midbrain, which are adjacent structures in the secondary vesicle stage of development. In the adult brain, the cerebellum seems close to the cerebrum, but there is no direct connection between them. The four ventricles and the tubular spaces associated with them can be linked back to the hollow center of the embryonic brain (see Table 13. A groove forms along the dorsal surface of the embryo, which becomes deeper until its edges meet and close off to form the tube. If this fails to happen, especially in the posterior region where the spinal cord forms, a developmental defect called spina bifida occurs. The closing of the neural tube is important for more than just the proper formation of the nervous system. The first type, spina bifida occulta, is the mildest because the vertebral bones do not fully surround the spinal cord, but the spinal cord itself is not affected. No functional differences may be noticed, which is what the word occulta means; it is hidden spina bifida. The other two types both involve the formation of a cyst—a fluid-filled sac of the connective tissues that cover the spinal cord called the meninges. The earlier that surgery can be performed, the better the chances of controlling or limiting further damage or infection at the opening. For many children with meningocele, surgery will alleviate the pain, although they may experience some functional loss. Because the myelomeningocele form of spina bifida involves more extensive damage to the nervous tissue, neurological damage may persist, but symptoms can often be handled. Complications of the spinal cord may present later in life, but overall life expectancy is not reduced. The caption for the video describes it as “less gray matter,” which is another way of saying “more white matter. The spinal cord is a single structure, whereas the adult brain is described in terms of four major regions: the cerebrum, the diencephalon, the brain stem, and the cerebellum. The coordination of reflexes depends on the integration of sensory and motor pathways in the spinal cord. The Cerebrum The iconic gray mantle of the human brain, which appears to make up most of the mass of the brain, is the cerebrum (Figure 13. The wrinkled portion is the cerebral cortex, and the rest of the structure is beneath that outer covering.

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Epileptic patients should be considered as normal discount 400mg levitra plus amex; one should not have a biased attitude towards them purchase cheap levitra plus on-line. Julius Cesar buy discount levitra plus 400mg, Napoleon generic 400mg levitra plus visa, Alfred Nobel, Vincent Van Gaugh, Jhonty Rhodes, and many other great personalities suffered from epilepsy, but still managed to excel in their respective professions. To help the epileptic patients “The Indian Epilepsy Association and Society” have been very active in several cities. Various activities are carried out to provide moral support to the patient and family members, and to help patients gain acceptance in the society. It is really sad and surprising that there is very little awareness among the general public regarding this disease. Like heart attack, knowledge of the risk factors can prevent the occurrence of the disease in majority of cases. If the warning signs are identified in time, immediate safety measures can be taken easily, so that in future any major stroke can be averted. After a stroke it is essential that immediate diagnosis and correct treatment be given to prevent permanent disabilities. This is the main aim behind providing detailed information of paralysis (brain stroke) in this chapter. Paralysis can occur due to obstruction in the blood circulation in the main arteries supplying blood to the brain. Due to the obstruction of some of the arteries of the brain, the blood circulation is affected leading to reduced nutrition and oxygen to brain cells, which hampers the normal working of these brain cells leading to a stroke. In 30% of these kind of patients there is a possibility of getting a bigger stroke attack in next five years. Thus, this serves as a warning for such patients to take good care of themselves in order to avoid future strokes. The doctors evaluate the extent, type and location of the damage to the brain on the basis of the signs and the severity of the paralytic attack. If the left side of the brain is affected then the right side of the body is paralyzed, and usually speech is also affected. Similarly, if the right side of the brain is affected, the left Main 4 Arteries Supplying Blood to the Brain side of the body gets paralyzed. The two arteries in the anterior portion of the neck are called the Carotid arteries and the arteries in the posterior part of the neck are called the vertebral arteries, which provide uninterrupted blood supply to the brain. The posterior arteries then merge to form the Basilar artery, which is one of the most important arteries of our body. If there is a constriction or obstruction in the main artery supplying blood to the brain due to a clot, the circulation of blood in the brain is hampered. With advancing age the inner lining of the damaged arteries thickens causing an obstruction or reduction in the blood flow. Increase of lipids in the blood can cause thickening of blood and a local clot formed resulting in Thrombosis, or a clot from the heart or any other part of the body may travel to the arteries of the brain, obstructing blood supply to the brain. In 20% of the cases rupture of a blood vessel due to high blood pressure or any other reason, causes paralysis. Symptoms similar to stroke can also occur in other diseases like infections of brain, brain tumor, lymphomas, multiple sclerosis, hysteria, head injuries etc. This paralysis is different from stroke and other associated symptoms can usually help in differential diagnosis. People beyond the age of 40, need regular medical examinations If any of the family member has suffered from a heart disease or a stroke, it is necessary for the other members to take extra precautions. It should also be noted that 40% of the patients of stroke have no apparent and visible risk factors worth accounting for the stroke. Feeling of weakness in one side of the body; the limbs of the affected side may stop working or become numb. Vertigo, blurring of vision, diplopia, sudden headaches, nausea or vomiting, weakness in both the legs, stumbling, sudden momentary unconsciousness or falling down. These symptoms prevail for certain period of time and if the symptoms are ignored and if no treatment is commenced, paralysis of a whole side ensues, with loss of speech and the patient may be unconscious. Blood Pressure: Blood pressure should be regularly checked and if it is high, proper medication should be taken to keep it under control. Even if a patient has come for any other disease or ailment, according to a notification of the National Stroke Association, it is the duty of the doctor to check the patient’s blood pressure. Ideally, systolic blood pressure should be around 130 to 140 while the diastolic blood pressure should be maintained at 80 to 90. Time and again it has been proved that by merely controlling blood pressure alone, 40 to 50% cases of paralysis and heart diseases can be prevented. There are many people who are not ready to accept that they are suffering from high blood pressure because they do not get any symptoms like headache or dizziness. Whenever the blood pressure is measured while taking the medication, it is bound to be normal and therefore the patient may discontinue the medication due to a false sense of security. On discontinuing the drugs, blood pressure starts increasing again, eventually resulting in paralysis or heart attack. Along with the right treatment, the patient should be careful about his lifestyle as well as eating habits. Jealousy, anger, negative thinking should be avoided and everyone should live in harmony, which will always be beneficial. Use of contraceptive pills should be reduced to bare minimum and other forms of contraception should be followed. The patients who have previously suffered a stroke or a heart attack should take drugs like Aspirin, Dipyridamol, Ticlopidine, Clopidogrel, etc; to keep the blood thin, as per prescription from the doctor. With the help of these drugs the chances of a heart attack or paralysis can be reduced by about 13% to 45%. If a patient has not suffered either a heart attack ©r a brain attack, but has definite risk factors e. This recent scientific invention has revolutionized the concept of treatment of heart attacks and paralysis and has averted several angioplasties, coronary bypass surgeries and perhaps carotid surgeries. Diagnosis : Paralysis is a disease of the brain and therefore it is necessary to get proper and timely treatment from an experienced Physician or a Neurophysician. Sometimes there can be another disease with similar symptoms and a scan will diagnose the same, preventing a fatal mistake e. As observed earlier the risk factors of stroke as well as heart diseases are the same and heart disease is comparatively more prevalent than stroke. Therefore, investigations relating to heart disease are essential in patients of paralysis to prevent heart disease. According to a scientific research, number of paralytic patients dying due to heart disease is far more than the deaths caused by stroke. For young patients of paralysis, who do not have blood pressure or diabetes, special investigations like anticardiolipin test, homocysteine tests etc. Details of the treatment of stroke : As soon as the symptoms of stroke or paralysis are seen, immediate treatment should be started in a hospital by an expert physician or a neurologist. If the patient gets a convulsion, it should be immediately brought under control and if he is suffering from blood pressure, diabetes etc then they should also be controlled immediately. Thrombolytic therapy : It is an undisputed fact that in case of thromboembolism, if immediate treatment is given with latest special techniques, in the first 3 to 6 hours of paralysis, then in many cases a) entire blocked artery opens up; b) the clot in the artery (thrombus) melts; c) the damage to the brain cells can be prevented or reduced. In foreign countries public awareness about stroke is very high and hence the person suffering from one is immediately taken to a hospital within 1 to 2 hours. We hope that the same happens in India too and the attitude of the people towards insurance changes for the better. The other therapies available till now cannot cure paralysis beyond six hours after the stroke, as they can not rejuvenate the brain cells, which have died due to lack of blood and oxygen. Antithrombotic therapy : This therapy is easily available in our country and it aims to stop the clot formation in the blood vessels. It includes anticoagulant drugs like, heparin, low molecular heparin, drugs of antiplatelet group, like aspirin, dipyridamol, abciximab and drugs of fibrinolytic group, like ancrod. However, they can lead to side effects like hemorrhage and therefore they need to be administered in the right dose with proper investigations. It is called strange because even after taking the necessary medications after the initial symptoms of stroke, the paralysis keeps on advancing for 2 to 4 days and eventually the entire side is completely paralyzed.

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The bronchoalveolar lavage (instilling a total of 180 mL of saline solution and obtaining the sample by aspiration of the bronchial contents) is an invasive technique and requires the use of anesthesia purchase generic levitra plus line, so its use in children must be well justified purchase levitra plus with american express. Diagnosis 539 Bronchoscopy may be useful in determining endobronchial involvement and also in distinguishing M buy generic levitra plus on line. Renal disease is a rare event in children order genuine levitra plus, but when it is suspected, overnight urine specimens must be collected in the early morning and immediately sent for analy- sis, as the tubercle bacilli poorly tolerate the acid pH of urine. Enhancement of the yield may be possible by staining any typical clot (bride veil) formed in cerebrospinal fluid specimens. Nevertheless, in children in whom bacilli in the respiratory secretions are sparse, results may be negative. In these cases, a single organism on a slide is highly suggestive and warrants further inves- tigation. Conventional cultures on Löwenstein-Jensen solid medium are commonly used in low-income countries, while automated culture methods are widely employed in high-income countries for the rapid detection and recovery of mycobacteria (Caminero 2003) (see Chapters 12 and 14). Specimens from body sites naturally contaminated, such as sputum and urine, re- quire a decontamination process prior to culture in order to allow the growth of mycobacteria in the culture media, without overgrowth of the commensal flora. According to several reports, the sensitivity and specificity of the nucleic acid amplification methods in smear-positive cases may exceed 95 %, but the sen- sitivity in smear-negative cases, which includes most of the pediatric cases, varies from 40 % to 70 % (Eisenach 1990, Morcillo 2001, Saltini 1998). Speci- ficity is even more controversial, and false positive results have been observed in up to 20 % of controls (Smith 1996). The size of induration and not erythema must be measured by placing the ruler transversally to the long axis of the forearm (ruler-based reading). Multiple puncture techniques should no longer be used because of its intrinsic limitations and inaccuracy (Arnadottir 1996, International Union Against Tuberculosis and Lung Disease 1991, World Health Organization 1963). For other high-risk groups, such as children with increased environmental exposure, or those younger than four years old, a reaction equal or greater than 10 mm is a positive result. False- negative results may be caused by recent vaccination with live-attenuated virus, anergy, immunosuppression, immune deficiency, or malnutrition (Flament 1994). Tuberculin skin test: cutoff size of reactive area for positive tuberculin reaction Cut off area (mm) ≥ 5 mm ≥ 10 mm ≥ 15 mm Contact to infectious cases with Children from high prevalence Children ≥ 5 years or without symptoms. Cost-benefit analyses have shown that universal school-based skin testing programs are not effective in finding ill children, and the targeted screening of high risk children is more efficient and less costly than screening all students. Bacteriological diagno- sis and drug susceptibility testing of the mycobacterium causing the disease in the index case is extremely important. It is often impossible to obtain a sputum from young children, so analyzing the strain isolated from the index adult case may be the only way to determine the appropriate treatment for the child (Chadna 2003, Comstock 1974, International Union Against Tuberculosis and Lung Disease 1991, Jacobs 1993). Nevertheless, the hilar region may be difficult to evalu- ate by a posteroanterior radiograph view, so the systematic inclusion of a lateral view radiograph is necessary. When one or several granulomas or calcifications are detected in the lung parenchyma or hilar/mediastinal lymph nodes (primary bipolar complex), these could just be evidence of a past infection with M. However, the absence of calcification in the lesions lends support to the possibility of active primary disease. A fan-shaped lesion on the radiograph is a manifestation of bronchial obstruction, leading to segmental disease characterized by atelectasis and consolidation of the involved area. Other chest radiographic observations include linear, interstitial and nodular densities, cavities with consolidation, empyema, bronchiectasis or focal masses. Computed tomography imaging can reveal basal cistern inflammation, hydrocephalus and meningeal enhancement, as well as focal parenchymal abnormalities, such as tuberculomas and infarction. In adults, tuberculous osteomyelitis usually originates in the epiphysis of long bones with spread into the adjacent joint space. However, computed tomography scans and magnetic resonance imaging are super- fluous when chest radiograph findings are diagnostic. There are several aspects of treatment that are markedly different in children and require special consideration, such as the availability of pediatric for- mulations, dosing, side effects, and follow-up (Correa 1997, Blumberg 2004). Treatment of asymptomatic tuberculosis infection The purpose of treating asymptomatic infection is to prevent the development of active disease in the future. Since infected children are at a high risk of developing active disease, all infected children should receive preven- tive chemotherapy (Miller 1993, Starke 1995). Guidelines for the application of preventive chemotherapy vary among countries and even communities in relation to the age of the infected children (Arnadottir 1996, International Union Against Tuberculosis and Lung Disease 1991). It is extremely important To exclude active dis- ease in order to avoid mycobacteria selection under drug pressure due to a chemo- 16. This is frequently unknown in several countries or regions, and should be evaluated before establishing a standard preventive treatment regimen in these areas. Treatment for exposure Although exposed adults are usually not treated, young children should receive chemotherapy during the exposure stage and until infection has been properly ex- cluded. Children treated for exposure should receive at least three months of an effective drug after contact with the source has been interrupted. There is no reason to restrict breastfeeding and contact between the infected mother and child must be encouraged. Perform a Mantoux test when the infant is aged four to six weeks and again at age three to four months. Evaluation of the infant includes chest radiograph and Mantoux test at age four to six weeks; if negative, the test must be repeated at age three to four months and again at six months. The amount of drug in breast milk is very small, and there has been no good documentation of adverse effects, although the infant should be given pyridoxine. Mothers who have received anti-tuberculosis drugs are much less infectious than those who have not received any treatment, due primarily to the reduction in the bacillary population in the lungs (Correa 1997, Starke 1997). In this situation, separation of the mother and infant is recommended until the mother is no longer contagious. The incidence of asymptomatic elevation in serum liver enzymes in children is usually lower than 2 %, and clinical hepatitis is less than 1 %. Routine tests of blood chemistry and serum hepatic enzymes are unnecessary unless the child has hepatic disease or dysfunction, or is also taking other potentially hepatotoxic drugs. Medi- cal examinations are recommended every four to six weeks to check for adverse reactions as well as to assure adherence to the treatment. Simultaneous administra- tion of pyridoxine is routinely prescribed only for breastfed babies, pregnant women and persons with poor dietary intake of this vitamin (Pape 1993). Careful follow-up and observation of the children is rec- 548 Tuberculosis in Children ommended, as none of the second-line drugs have been evaluated for preventive therapy. Drugs have been used in these circumstances include pyrazinamide, fluoroquinolones, and ethambutol, depending on the strain susceptibility pattern. The specific therapeutic regimen should be individually designed according to available drug susceptibility testing results, the tolerance of the patients for the drugs, and the continuous supply and availability of drugs for the whole duration of treatment (Canetti 1969, Heifets 2003, American Academy of Pediatrics 2003, American Thoracic Society 1994, American Thoracic Society /Centers for Disease Control and Prevention 2001, Blumberg 2004). Following the standard guidelines for new patients, the child must be given at least three drugs during the first phase of the treatment. Pediatric tuberculosis treatment 549 Treatment of respiratory disease Since the ’70s anti-tuberculosis treatment has become shorter, but with more drugs included in the treatment regimen. This problem becomes exacerbated in the pediatric population by the unavailability of pediatric formulations for all first-line drugs, the lack of sympto- matology and the poor radiographic improvement commonly seen in this age group. In the published clinical trials the overall suc- cess rate has been greater than 97 % for complete clinical and radiographic cure and 99 % for significant radiographic improvement during a two-year follow-up period. The incidence of relevant adverse events, mostly gastrointestinal upset or mild skin rash, was less than 2 %. Short courses of corticosteroids may be effective for children with enlarged hilar lymph nodes that compress the tracheal bronchial tree causing respiratory distress, localized emphysema, or severe segmental pulmonary disease. The most com- monly prescribed regimen is prednisone 1 to 2 mg/kg/day for 4 to 6 weeks with gradual tapering (Starke 2004). When it is possible to obtain cultures from older children, drug susceptibility test- ing should be performed. However, when an isolate can’t be obtained from the child or while waiting for cultures to grow, there are situations that raise suspicions 550 Tuberculosis in Children that the child may be infected with a drug resistant strain that could compromise the efficacy of the standard treatment regimen: an unidentified contagious source, several possible contagious sources in the child’s environment, or when the likely source case has a drug-resistant strain. Although streptomycin is a bactericidal drug, its use in children is restricted due to its parenteral administration and ototoxicity, so ethambutol is preferred. Drug treatment should last between 12 to 24 months, depending upon the anatomic location of and severity of the disease, and when the patient becomes bacteriologically negative, both by direct smear examination and by cultures, if possible. Drugs associated with frequent side ef- fects, such as cycloserine and ethionamide may be started at low doses and if toler- ated, gradually increased to the recommended dose. The use of fluoroquinolones in children remains controversial because of their potential for damaging cartilage growth. However, the later generation fluoroquinolones, such as moxifloxacin, have good bactericidal activity against M. Corticosteroids are useful when the host in- flammatory reaction contributes significantly to tissue damage or impairment of organ function.