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Trazodone dosed at <150 mg/day and bupropion would not be considered trials for this indication 60 ml rumalaya liniment muscle relaxant not working. Abilify Oral Solutions: The patient has been started and stabilized on the requested medication order rumalaya liniment 60 ml amex muscle relaxant examples. Trazodone dosed at < 150 mg/day would not be considered a trial for this indication buy rumalaya liniment 60 ml overnight delivery muscle relaxant comparison. Risperdal Oral Solution: The patient has a documented intolerance to the generic product risperidone. Versacloz Oral Solution: The patient has a medical necessity for a non-solid oral dosage form and is unable to use clozapine orally disintegrating tablets. If the request is for generic Reclast Injection (zoledronic acid) (Quantity Limit = 5 Calcitonin Nasal Spray, the patient has had a docmented intolerance to brand mg (one dose)/year) Zoledronic Acid Injection† (compare to Reclast®) Miacalcin. Treatmetn failure is defined as documented continued bone loss or fracture after one or more years despite Fortical®† (calcitonin) treatment with an oral bisphosphonate. For re-approval after 3 months, the patient must have had an improvement in symptoms. When injected intramuscularly, botulinum neurotoxins produce a presynaptic neuromuscular blockade by preventing the release of acetylcholine from the nerve endings. As a consequence of the chemistry and clinical pharmacology of each botulinum neurotoxin product, botulinum neurotoxins are not terchangeable, even among same sterotype products. Units of biological activity are unique to each preparation and cannot be compared or converted into units of another. It is important that providers recognize there is no safe dose conversion ratio—i. Failure to understand the unique characteristics of each formulation of botulinum neurotoxin can result in under or over dosage. If the diagnosis is Clinic Vivitrol® (naltrexone for extended-release injectable alcohol dependence, there must be a clinically compelling reason for use (e. Note: Re-approval requires evidence of decreased parenteral nutrition support from baseline. Flo-Pred® (prednisolone acetate) oral suspension solution All Others: The patient has been started and stabilized on the requested medication. All Other Brands: The prescriber must provide a clinically valid reason for the use of the requested medication including reasons why any of the generically available preparations would not be a suitable alternative. Note: Renewal of Prior Authorization will require supply = 30 days) documentation of member response. Qty Limit = 2 pumps/8 weeks 111 This is not an all-inclusive list of available covered drugs and includes only managed categories. Other Note: Please refer to “Dermatological: Antifungals: topical dosage preparations preferred. Denavir (penciclovir) 1% C Note: See Anti-Infectives: Antivirals: Herpes: Oral for ® Acyclovir, Zovirax: If prescribed for the treatment of oral herpes simplex infection, ® Zovirax (acyclovir) 5% C, O Sitavig the patient has had a documented side effect, allergy, or treatment failure (at least Xerese® (acyclovir 5%/hydrocortisone 1%) C one course of four or more days) with Denavir. Topicort Spray) not Temovate®/Cormax®) spray covered – use alternate dosage forms. Criteria for Approval Age > 2 years (requests will be approved for up to 1 year): The patient has a diagnosis of atopic dermatitis (eczema). Sh=shampoo, Sp=spray, Ss=suspension 118 This is not an all-inclusive list of available covered drugs and includes only managed categories. Please see the Quantity limit = 6 syringes/28 days for the first month regular) Humira and Cimzia Prior Authorization/Patient Enrollment Form for (Crohn’s starter kit);2 syringes/28 days ® subsequently Entyvio (vedolizumab) instructions. Briova may supply Remicade upon request or you may continue to Quantity limit = 300mgX 3/42 days, 300mg X 1 every obtain through your usual supplier. Note: Humira and Cimzia have been shown to be effective in patients who have been treated with infliximab but have lost respone to therapy. For approval of ranitidine ® capsules, the patient must have had a trial of ranitidine tablets. Additionally, renal impairment is not considered a contraindication to allopurinol use. Increlex® (mecasermin) Serostim® provocative growth hormone stimulation tests (insulin, arginine, levodopa, Zorbtive® propranolol, clonidine, or glucagon) showing results (peak level) <10ng/ml. Subsequent requests can be approved for up to 1 year with documentation of positive response to treatment with growth hormone. Criteria for Approval Adult: The patient must have one of the following indications for growth hormone: Panhypopituitarism due to surgical or radiological eradication of the pituitary. Authorization for continued use shall be reviewed at least every 12 months to confirm patient has experienced disease stability or improvement while on therapy. Note: Re-approval requires confirmation that the patient has responded to therapy (i. Patients may only continue on this dose when new to Medicaid if the patient has been taking this dose for 12 or more months without evidence of muscle toxicity. If the request is for Zocor 80 mg, the patient must have met the prior treatment length requirement and have a documented intolerance to the generic equivalent. For approval of Caduet, the patient must have also had a documented intolerance to the generic equivalent. Other Statin Combinations Advicor: The patient is unable to take the individual drug components separately. Benlysta has 142 This is not an all-inclusive list of available covered drugs and includes only managed categories. Quantity limit = 2 capsules/day Samsca® tablets (tolvaptan) Quantity limit = 15 mg Robinul, Robinul Forte: The patient has had a documented intolerance to generic tablets (1 tablet/day), 30 mg tablets (2 tablets/day) glycopyrrolate. Note: Re- approval requires confirmation that the patient has experienced an objective response to therapy (i. Authorization for continued use shall be reviewed to confirm that the patient has experienced an objective response to the therapy. Somatuline: The diagnosis or indication for the requested medication is Acromegaly. Xenazine: The diagnosis or indication for the requested medication is Huntington’s disease with chorea. Robaxin * (methocarbamol) 500mg, 750 mg tablets Tizanadine capsules, Zanaflex capsules: The prescriber must provide a clinically (Quantity limit = 8 tablets/day) ® valid reason why generic tizanidine tablets cannot be used. All Others: Requested nutritional supplement will be administered via tube feeding. Alaway , Zaditor 155 This is not an all-inclusive list of available covered drugs and includes only managed categories.

Just as with conventional medicines generic rumalaya liniment 60 ml on line spasms mid back, herbal remedies can interfere with your enlarged prostate treatment generic rumalaya liniment 60 ml amex spasms near ovary. There is no evidence at the moment to suggest that acupuncture or homeopathy can help control symptoms of an enlarged prostate discount rumalaya liniment 60 ml line muscle relaxant parkinsons disease. It is very important that you tell your doctor if you are taking any kind of herbal or complementary medicine. Reporting unusual side effects: The Yellow Card Scheme If you think you are experiencing a side effect from a medicine or herbal remedy that is not mentioned in the information leafet that comes with it, then you can report it using the Yellow Card Scheme. There are three ways you can report a side effect: • use the online Yellow Card form at www. There are several different types of surgery available for treating an enlarged prostate. There are some other less common procedures that are usually only available as part of a clinical trial or through private healthcare. They include: • photoselective vaporisation of the prostate • minimally invasive surgery, such as transurethral needle ablation or transurethral microwave therapy • transurethral vaporisation resection of the prostate. The types of surgery available will vary from hospital to hospital depending on the training and experience of the doctors. The types of surgery available to you may also depend on the size of your prostate and any other health problems you have. Your doctor or nurse will discuss the advantages and disadvantages of each type of surgery they offer, to help you decide what is right for you. Although many men fnd surgery effective, some men will not see a signifcant improvement in their symptoms after surgery. The tube has a small camera on the end so that the surgeon can get a good view of the prostate. They then pass an electrically-heated wire loop through the tube and use it to remove small pieces of prostate tissue. During the operation, fuid is passed into your bladder to clear away the small pieces of prostate tissue that have been removed. You will have a catheter to drain urine from your bladder for two to three days after surgery. Before you go home, your nurse will remove your catheter and check that you are passing urine easily. If you have any of these symptoms after surgery, tell your doctor or nurse straight away. The pieces of prostate tissue that are removed pass into the bladder and are removed with a different instrument. You will either be asleep during the operation (general anaesthetic) or you will be awake but unable to feel anything in the area being Specialist Nurses 0800 074 8383 prostatecanceruk. After surgery, you will have a catheter to drain urine from your bladder for 12 to 24 hours. An electric current is passed into a roller ball (like a computer mouse ball) and this heats up the prostate tissue blocking the urethra, causing it to burn away. You will either be asleep during the operation (general anaesthetic) or awake but unable to feel anything in the area being operated on (spinal anaesthetic). After surgery, you may have a catheter to drain urine from your bladder for 9 to 24 hours. Around 9 out of 100 men (9 per cent) fnd that they cannot pass urine at all in the hours after their catheter has been removed. If you have a small prostate but are still having urinary symptoms, your doctor or nurse may recommend bladder neck incision. You will either be asleep during the operation (general anaesthetic) or you will be awake but unable to feel anything in the area being operated on (spinal anaesthetic). Then they pass an instrument through the tube and use this instrument to make a few small cuts (usually one or two) in the neck of the bladder and in the prostate gland. A small number of men fnd that they cannot pass urine at all in the hours after their catheter has been removed. A disadvantage of bladder neck incision is that prostate tissue is not removed so it is not possible to check for signs of cancer. It is not commonly used to treat an enlarged prostate, but you may be offered it if you have a very large prostate or if you have other medical problems such as large bladder stones. The inner part of the prostate gland is removed through a cut in the stomach area under general anaesthetic. The length of time you spend in hospital depends on your doctor’s advice and your recovery, but is usually between four and six days. An advantage of open prostatectomy is that the prostate tissue can be checked for signs of cancer once it has been removed. At frst, you may fnd that you pass urine more often and sometimes urgently, but this usually improves over time. Your doctor or nurse can give you advice on pelvic foor exercises that may help to improve your bladder control. Read our Tool Kit fact sheet Pelvic foor muscle exercises or call our Specialist Nurses on our confdential helpline. If exercises do not help, your doctor or nurse can discuss other treatment options with you. Sometimes the urine clears and then you see a small amount of blood 5 to 10 days after your operation. Scar tissue from the operation can narrow the urethra or bladder neck after a period of time, slowing down the fow of urine. Instead, the semen passes into your bladder when you orgasm and is passed out of the body the next time you urinate. It happens because the neck of the bladder sometimes becomes wider during the operation. Men who have retrograde ejaculations may not be able to father children through sex. We don’t know if erection problems are caused by the operation or by other factors, such as age and other health conditions. If you have good erections before the operation, you may be less likely to have problems afterwards. These treatments are usually only available as part of a clinical trial or through private healthcare.

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Oral candidiasis Look routinely for oral candidiadis as it interferes with feeding generic 60 ml rumalaya liniment with amex muscle relaxant breastfeeding; see treatment Chapter 3 purchase rumalaya liniment 60 ml without a prescription spasms after hemorrhoidectomy, Stomatitis order rumalaya liniment 60 ml amex spasms medication. As in children, any malnourished patient presenting with significant complications should initially be hospitalised, regardless of the anthropometric criteria above. Adults: weight gain of 10-15% over admission weight and oedema below Grade 2 and good general condition. Nutritional treatment follows the same principles as in children, but the calorie intake in relation to body weight is lower. Routine treatment is similar to that in children, with the following exceptions: – Measles vaccine is only administered to adolescents (up to age 15). Initially stable and partial obstruction may worsen and develop into a life-threatening emergency, especially in young children. Clinical features Clinical signs of the severity of obstruction: Danger Obstruction Signs signs Complete • Respiratory distress followed by cardiac arrest Imminent • Severe respiratory distress with cyanosis or saturation O2 < 90% complete • Agitation or lethargy • Tachycardia, capillary refill time > 2 seconds Severe • Stridor (abnormal high pitched sound on inspiration) at rest Yes • Severe respiratory distress: – Severe intercostal and subcostal retractions – Nasal flaring – Substernal retractions (inward movement of the breastbone during inspiration) – Severe tachypnoea Moderate • Stridor with agitation • Moderate respiratory distress: – Mild intercostal and subcostal retractions No – Moderate tachypnoea Mild • Cough, hoarse voice, no respiratory distress Management in all cases – Examine children in the position in which they are the most comfortable. Perform maneuvers to relieve obstruction only if the patient cannot speak or cough or emit any sound: – Children over 1 year and adults: Heimlich manoeuvre: stand behind the patient. Place a closed fist in the pit of the stomach, above the navel and below the ribs. Place the other hand over fist and press hard into the abdomen with a quick, upward thrust. Perform one to five abdominal thrusts in order to compress the lungs from the below and dislodge the foreign body. With the heel of the other hand, perform one to five slaps on the back, between shoulder plates. Perform five forceful sternal compressions as in cardiopulmonary resuscitation: use 2 or 3 fingers in the center of the chest just below the nipples. Repeat until the foreign body is expelled and the patient resumes spontaneous breathing (coughing, crying, talking). If the patient loses consciousness ventilate and perform cardiopulmonary rescucitation. Differential diagnosis and management of airway obstructions of infectious origin Timing of Infections Symptoms Appearance symptoms Viral croup Stridor, cough and moderate Prefers to sit Progressive respiratory difficulty Epiglottitis Stridor, high fever and severe Prefers to sit, drooling Rapid respiratory distress (cannot swallow their own saliva) Bacterial Stridor, fever, purulent secretions Prefers to lie flat Progressive tracheitis and severe respiratory distress Retropharyngeal Fever, sore throat and painful Prefers to sit, drooling Progressive or tonsillar swallowing, earache, trismus abscess and hot potato voice – Croup, epiglottitis, and tracheitis: see Other upper respiratory tract infections. Management of other causes – Anaphylactic reaction (Quincke’s oedema): see Anaphylactic shock (Chapter 1) – Burns to the face or neck, smoke inhalation with airway oedema: see Burns (Chapter 10). Clinical features – Nasal discharge or obstruction, which may be accompanied by sore throat, fever, cough, lacrimation, and diarrhoea in infants. Treatment – Antibiotic treatment is not recommended: it does not promote recovery nor prevent complications. Most acute sinus infections are viral and resolve spontaneously in less than 10 days. Acute bacterial sinusitis may be a primary infection, a complication of viral sinusitis or of dental origin. The principal causative organisms are Streptococcus pneumoniae, Haemophilus influenzae and Staphylococcus aureus. It is essential to distinguish between bacterial sinusitis and common rhinopharyngitis (see Rhinitis and rhinopharyngitis). Without treatment, severe sinusitis in children may cause serious complications due to the spread of infection to the neighbouring bony structures, orbits or the meninges. Clinical features Sinusitis in adults – Purulent unilateral or bilateral discharge, nasal obstruction and – Facial unilateral or bilateral pain that increases when bending over; painful pressure in maxillary area or behind the forehead. Sinusitis is likely if symptoms persist for longer than 10 to 14 days or worsen after 5 to 7 days or are severe (severe pain, high fever, deterioration of the general condition). Sinusitis in children – Same symptoms; in addition, irritability or lethargy or cough or vomiting may be present. If the diagnosis is uncertain (moderate symptoms < 10 days) and the patient can be re- examined in the next few days, start with a symptomatic treatment, as for rhinopharyngitis or viral sinusitis. Other treatments – For sinusitis secondary to dental infection: dental extraction while under antibiotic treatment. The majority of cases are of viral origin and do not require antibiotic treatment. Group A streptococcus is the main bacterial cause, and mainly affects children age 3 to 14 years. Clinical features – Features common to all types of pharyngitis: throat pain and dysphagia (difficulty swallowing), with or without fever. Less common forms: • Vesicular pharyngitis (clusters of tiny blisters or ulcers on the tonsils): always viral (coxsackie virus or primary herpetic infection). Immunisation protects against the effects of the toxin but does not prevent individuals from becoming carriers. Close monitoring of the patient is essential, with immediate availability of equipment for manual ventilation (Ambu bag, face mask) and intubation, Ringer lactate and epinephrine. If there is no allergic reaction (no erythema at the injection site or a flat erythema of less than 0. Management of close contacts Close contacts include family members living under the same roof and people who were directly exposed to nasopharyngeal secretions of the patient on a regular basis (e. Treatment – In the absence of inspiratory stridor or retractions, treat symptomatically: ensure adequate hydration, seek medical attention if symptoms worsen (e. Monitor heart rate during nebulization (if heart rate greater than 200, stop the nebulization). Age 3 months 4-6 months 7-9 months 10-11 months 1-4 years Weight 6 kg 7 kg 8 kg 9 kg 10-17 kg Dose in mg 3 mg 3. Epiglottitis Bacterial infection of the epiglottis in young children caused by Haemophilus influenzae, it is rare when Hib vaccine coverage is high. Avoid any examination that will upset the child including examination of the mouth and throat. Treatment – In case of imminent airway obstruction, emergency intubation or tracheotomy is indicated. The intubation is technically difficult and should be performed under anaesthesia by a physician familiar with the procedure. The dose is expressed in amoxicillin: Children < 40 kg: 80 to 100 mg/kg/day in 2 or 3 divided doses (use formulations in a ratio of 8:1 or 7:1 exclusively). Bacterial tracheitis Bacterial infection of the trachea in children, occurring as a complication of a previous viral infection (croup, influenza, measles, etc. Common precipitants of otitis externa are maceration, trauma of the ear canal or presence of a foreign body or dermatologic diseases (such as eczema, psoriasis).

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Drugs Considered Hazardous women discount rumalaya liniment 60 ml line spasms while eating, but some can apply to men only (such as re- General Approach to Handling duced fertility or sperm count) or to both men and Hazardous Drugs women purchase rumalaya liniment 60 ml with mastercard muscle relaxant remedies. Tese include workers who are excluded from the mended standard precautions or universal precau- susceptible populations for specifc reasons such as tions be taken in handling hazardous drugs buy rumalaya liniment 60 ml on-line muscle relaxant erectile dysfunction. In addition, drugs for which the the addition of many non-antineoplastic drugs and manufacturer includes safe-handling guidance in drugs in tablet and/or capsule form to the list, no the package insert are indicated. Note that tive equipment and ventilated engineering controls many of these drugs may also pose a reproduc- for some of the various scenarios in which a drug tive risk for susceptible populations (Table 1). Note that some of these drugs may jor handling events typically seen in health care. Defning Hazardous Drugs Group 3: Drugs that primarily pose a reproduc- tive risk to men and women who are actively Hazardous drugs include those used for cancer che- trying to conceive and women who are pregnant motherapy, antiviral drugs, hormones, some bioen- or breast feeding, because some of these drugs gineered drugs, and other miscellaneous drugs. Drugs considered hazard- or may not pose a risk to health care workers, some ous include those that exhibit one or more of the may pose a risk to patients. Teratogenicity or fertility impairment in animal studies tablished safety program [McDiarmid et al. Evidence of serious organ or other toxicity at low doses in animal models or treated patients. Te † All drugs have toxic side efects, but some exhibit toxicity at criteria are prioritized to refect the hierarchy of low doses. Te level of toxicity refects a continuum from rel- potential toxicity described below. Since the haz- atively nontoxic to production of toxic efects in patients at ardous drugs covered by the Alert were designed as low doses (for example, a few milligrams or less). For exam- ple, a daily therapeutic dose of 10 mg/day or a dose of 1 mg/ therapeutic agents for humans, human toxicity pro- kg per day in laboratory animals that produces serious organ fles should be considered superior to any data from toxicity, developmental toxicity, or reproductive toxicity has animal models or in vitro systems. Under all circumstances, an tal toxicity [56 Fed Regist 63798–63826 (1991)], and evaluation of all available data should be conducted to protect reproductive toxicity [61 Fed Regist 56274–56322 health care workers. Physical characteristics of the agents (such sponses from multiple test systems are needed before precau- as liquid versus solid or water versus lipid solubility) tions can be required for handling such agents. It looks for tumors in multiple organs and and bioengineered drugs interfere with cell growth or for tumors that are not rodent-specifc. However, ad- cells, resulting in toxic side efects for treated patients verse outcomes in several in vitro tests will be and their ofspring. Al- absence of maternal toxicity are considered rele- though the antineoplastic drugs remain the principal vant. Drugs in hazardous because they are potent (small quantities Category D are ofen listed as hazardous, but it produce a physiological efect) or cause irreversible will depend on the individual drug. As the use and number of these potent drugs able human data are considered signifcant. For example, an- defnition (a daily therapeutic dose of 10 mg/day tineoplastic drugs such as cyclophosphamide have or a dose of 1 mg/kg per day in laboratory ani- immunosuppressant efects that proved benefcial mals) is used as a benchmark. Tis doc- formation for determining whether a drug is haz- ument presents guidance for making such a facili- ardous. When a drug has been judged to be hazard- ty-specifc list (see section entitled How to Generate ous, the various precautions outlined in the Alert Your Own List of Hazardous Drugs). Also newly purchased drugs should be evaluated against included is a list of drugs that should be handled as the organization’s hazardous drug criteria and add- hazardous. When applying the criteria for a hazard- ed to the list if they are deemed hazardous. If so, the list of hazardous drugs in this docu- there may be a concern, it is prudent to handle them ment will help employers and workers to determine as hazardous drugs until adequate information be- when precautions are needed. Some drugs defned as hazardous may sidered to be hazardous and removing those that re- not pose a signifcant risk of direct occupational expo- quire reclassifcation. However, they may pose a risk if the formulations are altered, such as by crushing tablets or making solutions from them outside a ventilated cabi- How to Generate Your Own List net [Simmons 2010; Goodin et al. Uncoated tab- lets may present a risk of exposure from dust by skin of Hazardous Drugs contact and/or inhalation when the tablets are counted [Shahsavarani et al. Tablet and capsule forms of hazardous drugs program is the identifcation of all hazardous drugs should not be placed in automated counting ma- a worker may encounter in the facility. Institutions may wish to com- opening capsules should be avoided and liquid for- pare their lists to the listing in this document or on mulations should be used whenever possible. Local hazard communication programs Where to Find Information should provide for assessment of new drugs as they enter the marketplace and, when appropriate, reas- Related to Drug Toxicity sessment of their presence on hazardous drug lists as toxicological data become available to support Practice-specifc lists of hazardous drugs (usually re-categorization. Toxicological data are ofen in- developed by pharmacy or nursing departments) complete or unavailable for investigational drugs. Here are some of the resources care but also to others who support patient care by that employers can use to evaluate the hazard po- participating in product acquisition, storage, trans- tential of a drug: portation, housekeeping, and waste disposal. If any of the documents mention carcinoge- Reports and case studies published in medical nicity, genotoxicity, teratogenicity (Section 13 in and other health care profession journals package insert), or reproductive or developmental Evidence-based recommendations from other toxicity (Section 8), or if the package insert contains facilities that meet the criteria defning hazard- safe-handling warnings (Section 16), use the pre- ous drugs cautions stipulated in the Alert. Identifcation of Hazardous Te list of hazardous drugs will be updated peri- odically on the website, hpp://www. Te following list (Tables 1–3) contains those drugs Tis list supersedes both the 2004 list, http://www. Occup Med: ment of rheumatoid arthritis with cyclophospha- State of the Art Rev 12(1):67–80. Establishing airborne ex- Goodin S, Grifth N, Chen B, Chuk K, Daouphars M, posure control limits in the pharmaceutical industry. Te importance of human data in the recommendations from an international pharmacy establishment of occupational exposure limits. Lyon, uation of occupational exposure to tablet trituration France: World Health Organization, International dust [abstract]. Oral chemotherapeutic drugs: han- Kaestli L-Z, Fonzo-Christe C, Bonfllon C, Desmueles J, Bonnabry P [2013]. Imple- mentation of a safety program for handling hazard- ous drugs in a community hospital.

Water Treatment Manual: Disinfection Automatic shut down should be established if the chlorine concentration after the contact period falls below 0 order rumalaya liniment 60 ml amex muscle relaxant spray. For larger sites in particular best 60 ml rumalaya liniment spasms definition, it may be advisable to provide shut down in the event of low chlorine before the contact tank rumalaya liniment 60 ml with amex muscle relaxant comparison, to avoid accumulation of non-disinfected water in the contact tank. Clear guidance should be provided on dealing with alarms, which should include: Actions to be taken, and a checksheet to ensure the actions are carried out. Names and telephone details for the necessary contacts (primary contact and deputy. Names and telephone details for senior managers and health authority contacts, and guidance on when there could be health implications that would require these to be contacted. Actions to be taken would be site specific, but could include for example: Check that the chlorine monitor is reading correctly by taking a manual measurement. Check for changes in raw water quality that could have increased chlorine demand (ammonia, colour). Take works out of supply if this has not happened automatically and if the target residual cannot be restored. Such residuals are usually necessary to prevent contamination of treated water during the subsequent distribution of drinking water to consumers and to quality assure its quality to the consumer. The targeted goals of the pre- treatment, necessary to ensure the efficacy of the designer’s chosen system and its ability to achieve the target pathogen inactivation levels established with respect to bacteria, viruses and protozoa. The following sections of this guidance should be read in conjunction with the foregoing flowchart where clarification of the issues is required in relation to the decisions contained therein. This validation approach is used for small water systems which are usually operated on an on/off basis 2 based on a fixed dose delivery of 40mJ/cm dose. Mechanical Major Both Lamp wipe function fails which uncorrected may Wiper Failure alarm compromise the efficacy of the system due to lamp fouling Lamp Ballast Major Both Single lamp/ballast failure identified failure alarm Critical Both Multiple lamp/ballast failures identified. It is best to calibrate sensors in both duty and standby units where they exist to ensure that both sensors are ready for use at any time. It is recommended that particular attention be paid to the minimising such off-specification events where the risk of a specific pathogen is high and where other parallel treatment and disinfection methods (where used) are incapable of removing or inactivating the particular pathogen. Such flowcharts assist in necessary decision making surrounding instrumentation calibration, fouling of lamp sleeves and the necessity for lamp and sensor replacement. Introduction In accordance with the Drinking Water Safety Plan risk-based approach to managing drinking water quality, “risk assessment and risk management …. Operational procedures and consequent troubleshooting of disinfection systems will have to appreciate the influence of source risks and the efficacy of pre-treatment systems upstream of both primary disinfection and residual generation disinfection systems. This Appendix provides guidance in relation to the management of source risks and the necessary pre- treatment issues in respect of each of the different disinfection technologies in common use in Ireland. This guidance in respect of the prevention and mitigation of disinfection system malfunction is discussed as follows under the distinct headings of Appreciation of source risks to disinfection efficacy Management of treatment risks upstream of disinfection Maintenance of disinfection equipment and troubleshooting of system malfunctions. This guidance does not seek replace the manufacturer’s manual relating to the operation and maintenance of disinfection equipment or the component instrumentation necessary to monitor and verify the various disinfection technologies. The following guidance shall be read in conjunction with the appropriate instrument manuals. Appreciation of source risks to disinfection efficacy The realisation of risks associated with raw water changes or seasonal variations in source waters is important in the Irish context, due to the heavy reliance in Ireland on surface water sources and on groundwater sources susceptible to surface water contamination. These 143 Water Treatment Manual: Disinfection variations may require treatment systems and alarmed monitoring instrumentation upstream of disinfection systems themselves to be designed to cope with changes in key water quality parameters affecting their operation. Less source risk and variation in raw water quality parameters is associated with groundwaters from deep aquifers although groundwaters abstracted in areas with shallow soils over an underlying karstified limestone can demonstrate surface water risks 3. Management of treatment risks upstream of disinfection As discussed in the various sections of the Guidance Manual referring to the common disinfectants used in Ireland, the type of treatment that water is subjected prior to primary disinfection, and the way that treatment is managed and operated, can have a very significant influence on the performance of disinfection systems and their verification in use under the Drinking Water Regulations. The chapters of the Manual and the practical guidance Appendices, relating to various chemical and non-chemical disinfectants used for primary disinfection, details which water quality parameters affect the efficacy of the various disinfection systems. In the case where chemical are used as primary disinfectants, the Ct tables set out in the manual for each disinfectant detail the adverse effect of low temperatures (in the case of ozone and chlorine dioxide) and high pH and temperature variations in the case of chlorine. The Manual also details the risks associated with different chemical disinfectants with respect to both organic and inorganic disinfection by-product formation. While the risks are summarised as follows, operators should refer to the Manual and the particular practical guidance appendices for more detail. Chapter 4 of this Manual details the use and efficacy of chlorination in various forms (gas, bulk delivered hypochlorite or on site generated hypochlorite) as either a primary disinfectant following treatment or a secondary disinfectant (in combination with another disinfectant) or at a chlorine booster station on the distribution network. In the case of each possible cause it sets out what the likely symptoms of malfunction and the remedial action to be taken together with possible preventative operational practices or maintenance to be taken 145 Water Treatment Manual: Disinfection Malfunction: Possible Cause Fault Analysis Possible prevention Corrective action Pathogens detected in supply? Routine maintenance of dosing Analyse fault and repair Insufficient Dosing Pump pump, regular calibration of pump chlorine malfunction due to Is free chlorine concentration less than Manually dose reservoir with delivery curve and checking of pump residual incorrect calibration target level for adequate chlorination at chlorine pending pump re- dose-controller. Scheduled sampling and testing for Change dose controller settings, if Insufficient Calculated Chlorine residual chlorine on surface water operating correctly. Implement feedback control of following changes of water quality dosing using residual monitoring Is the calculated dose adequate for Digital display of dose rate in required target Ct value? Setpoint alarm generation on colour Consider additional feedback Insufficient Flow proportional Is the chlorine demand variable? Is contact time to residual monitoring overly residual working properly calibration long? Is possible hypochlorite decay taken Regular monitoring of hypochlorite account of in dose? Increase dose pending corrective Insufficient Feedback dose Is the chlorine demand variable? Regular monitoring of hypochlorite action chlorine control at re- concentrations Consider relative positions of Is chlorine properly mixed at residual residual chlorination stations dosing and residual sampling monitoring? Proper mixing at residual sampling not working properly points Is possible hypochlorite decay taken point account of in dose? Regular checking of calibration Increase dose pending corrective Insufficient Dose controller not action. Programme the controller based residual on revised calibration Water Treatment Manual: Disinfection Malfunction: Possible Cause Fault Analysis Possible prevention Corrective action Pathogens detected in supply? Use of a dose control strategy capable of reacting to raw water poor water quality.

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Second degree haemorrhoids prolapse discount rumalaya liniment 60 ml overnight delivery muscle relaxant cyclobenzaprine high, but reduce spontaneously buy 60 ml rumalaya liniment muscle relaxant long term use, whereas third degree haemorrhoids prolapse and have to be replaced manually or remain prolapsed permanently until repaired cheap rumalaya liniment 60 ml on line spasms near temple. Haemorrhoids developing during pregnancy should be managed conservatively as most will resolve after delivery. The symptoms and signs that accompany jaundice often give helpful clues to the underlying cause. In adults and children, hyperbilirubinaemia may result in hepatic encephalopathy (See sections on Chronic Hepatitis, Obstructive Jaundice and Liver Failure). Jaundice in neonates can result in kernicterus because of the consequences of hyperbilirubinaemia on the brain of the newborn. Jaundice appearing in the first 48 hours after birth, or a bilirubin concentration >170 micromol/L in premature infants, or >255 micromol/L in full-term infants, warrants investigation. However, jaundice appearing from the third day after birth onward is usually physiological. Exchange transfusionis the definitive treatment for Hyperbilirubinaemia that has reached the level where kernicterus may occur. Monitor heart rate, respiratory rate, bilirubin and blood glucose during the procedure. Stop the exchange transfusion if the heart rate fluctuates by more than 20 beats/minute. The threshold for intervention by phototherapy or exchange transfusion should be lower in the following cases: in sick or low birth weight babies, or following asphyxia, prolonged hypoxemia, acidosis and sepsis. Since there is no exact test to determine the risk of kernicterus and hence the level at which exchange transfusion is necessary the following rule of thumb has proved useful as a guide; • Serum bilirubin of more than 340 micromol/L in term infant i. It may present as an acute illness with jaundice and altered liver function tests. When symptoms, signs or laboratory abnormalities persist for more than 6 months it is considered that the hepatitis is chronic. Chronic hepatitis can progress to liver cirrhosis, portal hypertension with upper gastrointestinal bleeding, hepatic encephalopathy and hepatocellular carcinoma. Adults at risk (especially health workers) should be immunized against Hepatitis B infection after initial assessment of their immunological status regarding previous exposure to the virus. A normal and properly balanced diet, consists of food that has sufficient amounts of proteins necessary for growth and maintenance, carbohydrates and fats necessary for energy and vitamins and minerals for protecting against disease. Malnutrition occurs when there is a deficiency in intake of some or all of the above nutrients. It is most commonly seen in children less than five years, particularly after weaning. In many cases, the malnourished child is brought to the health unit because of other complaints such as diarrhoea, vomiting, fever, worms or cough. An infection in a malnourished individual may thus become very severe and result in death. A child suffering from malnutrition may have features of marasmus, kwashiorkor or both (marasmic-kwashiokor). The bleeding may be due to defective blood vessels, platelet disorders or clotting factor deficiency. The pattern of bleeding is a helpful guide to its cause: in platelet and vessel wall defects, bleeding is usually into skin and mucosal surfaces like the gums, nose, gastrointestinal tract; in coagulation factor deficiency (e. In newborns with Vitamin K deficiency (which leads to multiple coagulation factor deficiency) spontaneous bleeding occurs from various sites such as the umbilical cord, gastrointestinal tract, scalp, brain. Patients may be severely anaemic and in haemorrhagic shock if there is a large bleed. Note For information on appropriate blood products for various bleeding disorders see “National Guidelines for the Clinical Use of Blood and Blood Products in Ghana” for more details. The possession of one normal haemoglobin (haemoglobin A) together with one abnormal haemoglobin (e. Sickle cell disease patients may present either in the steady state, in crises or with complications. The crises are commonly vaso-occlusive (precipitated by cold weather, dehydration, infection, ischaemia or physical exertion), which often cause pain in the bones. In sequestration crises, the spleen and liver enlarge rapidly due to trapping of red blood cells. Patients with sickle cell disease should be encouraged to have periodic check-ups at a Sickle Cell Clinic. Transfusion will be necessary if haemoglobin level < 5 g/dl In the Steady State • Folic acid, oral, Adults 5 mg daily Children > 1 year; 5 mg daily < 1 year; 2. The abnormal plasma cells in the bone marrow result in a reduction in normal blood cell production and erosion of bone with release of calcium. The abnormal immunoglobulin in blood results in hyperviscosity, renal failure and impaired ability to fight infections. Follow-up can be done by a physician specialist with guidance from the haematologist. There are two main types of leukaemia depending on the type of white cell affected. Each can further be divided into acute (where the patient falls suddenly ill) and chronic (where the patient may have been harbouring the disease for months and occasionally years without knowing). Follow-up can continue at a regional centre by a physician under the distant guidance of a haematologist in the case of chronic leukaemias. From the tertiary centre, patients with a good chance of cure by bone marrow transplant and who have a stem cell donor should be referred to the appropriate centre. There are three clinical variants - the endemic, sporadic and immunodeficiency associated forms. The endemic form is found in tropical and malaria endemic regions like Ghana and commonly presents as a jaw swelling with loosening of the associated teeth. Follow-up can continue at a regional centre by a physician under the distant guidance of a haematologist. The vaccine protects all children against Diptheria, Pertussis, Tetanus, Hepatitis B and Haemophilus influenzae Type B.