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The Delicate Task of Talking to Children About Marijuana

Oral CBD/Ketamine 5.1.2.

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04.08.2018

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  • Oral CBD/Ketamine 5.1.2.
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  • Bioavailability of oral and smoked CBD in humans was found . Oral CBD/ Ketamine. One crossover study examined the effects of oral. Finally, preliminary clinical trials suggest that high-dose oral CBD ( .. Oral CBD/Ketamine. One crossover study examined the effects of oral CBD . Cannabidiol (CBD) oral solution (CBD-OS) is a first-in-class antiepileptic drug ( AED) for the adjunctive treatment exposure to drug, the label states that CBD- OS should be taken with food. Ketamine & Isoflurane.

    Oral CBD/Ketamine 5.1.2.

    Hydroceles without hernia in neonates: This is the only exception in which surgical treatment may be delayed. Repair of hydroceles in neonates without the presence of hernia is typically delayed for 12 months because the connection with the peritoneal cavity via the processus vaginalis may be very small and may have already closed or be in the process of closing. If the hydorcoele persists after this observation period, operative repair is indicated and appropriate.

    Postpone the operation in the event of upper respiratory tract infection,otitis media, or significant rash in the groin. FOLLOW UP No specific limitations are indicated once the diagnosis of an inguinal hernia has been established; however, following operative repair, avoidance of major physical activity for 1 week is recommended.

    After that time, the patient is allowed to participate in physical activities eg, sports, swimming, running. Children younger than 5 years are likely to recover extremely quickly from surgery; they are typically capable of returning to their normal level of activities within hours of surgery. Optimal Standards of Treatment in Situations where technology and resources are limited a.

    Similar generic diagnostic criteria apply. A typical history and physical finding are adequate for diagnosis. Investigations are not required other than for anaesthetic purposes. Rarely, ultrasonography and diagnostic laparoscopy may be indicated c. Treatment is surgery -herniotomy operation that aims at ligating the patent processus vaginalis at the internal ring after reduction of contents into the abdomen b.

    Surgery is indicated if hydrocoele persists beyond the 2nd year and if it is rapidly growing is size. All hernia and hydrocoele repairs in infants and children MUST be performed by a qualified pediatric surgeon. Standard Operating procedure a. Outpatient care is adequate for diagnosis and follow up in most children ii. Clinical evaluation usually sufficient to diagnose c. A child with a hernia needs referral to a higher centre if: At Super Specialty Facility in Metro location where higher-end technology is available Doctor makes a clinical diagnosis, counsels the family and plans surgery- a pediatric surgeon performs the surgery b.

    Surg Clin North Am. Inguinal and umbilical hernia repair in infants and children. Laparoscopic approach to incarcerated and strangulated inguinal hernias.

    Neonatal cholestatis is a pathological condition in the newborn where in bile flow from the liver is reduced. Neonatal Cholestasis Syndrome NCS includes a wide spectrum of clinical conditions ranging from congenital malformations of the hepatobiliary tree, infections, inborn errors of metabolism to some of the recently identified clinical conditions with or without genetic predilection.

    Most of these disorders have linkage with insults during antenatal, natal and postnatal periods. The average age of presentation to a specialized center is 3. If the previous sibling has had liver disease antenatal counselling and referral for further evaluation may be necessary.

    Optimal Standards of Treatment in Situations where technology and resources are limited Standard Operating procedure 4. Resuscitation if required, 5. Correction of Hypoglycemia 6. Administration of Vitamin K 0. Child needs admission if 1. Baby who is clinically well, feeding well and has no evidence of hypoglycemia or coagulopathy can be investigated as an outpatient No role of day care admission.

    All workup at this level must be completed by 48 hours 1. Clinically unwell, poor feeding, poor weight gain 3. GGT is raised in all cases of cholestasis except in one of the bile acid synthetic defects.

    Serum albumin does not fall till late. None of the biochemical tests are of deciding value and at best reflect the degree of damage to liver. Tests directed towards infective and metabolic causes: Role of Hida Scan Hepatobiliary scintigraphy, after a 5 day priming with phenobarbitone,is useful.

    Excretion of the radio-tracer into the gut rules out biliary atresia. However, the converse is not true and absence of gut excretion of radiotracer requires further evaluation. Coagulopathy and ascitis are contraindications for percutaneous liver biopsy.

    Spontaneous perforation of bile ducts 6. Avoid hyper- vitaminosis as it can enhance fibrosis. If the child has rickets give a dose of 60, IU. Perform prothombin time PT monthly. Administer injectable vitamin K if PT is prolonged. Referral criteria for a specialist centre: Any case of neonatal cholestasis as defined by above parameters with deranged liver function tests to be referred to tertiary centre for further management.

    Child needs to be referred to a specialist pediatric liver unit if, 1. Evidence of progressive liver failure 2. Evidence of complications such as portal hypertension, SBP, Respiratory distress, pathological fractures. Failure of Kasai operation Evidence of liver cirrhosis in biopsy Jaundice not cleared by 2 months after surgery 4.

    Considerations for liver transplant Situation 2: Referred cases from secondary centres or any newborn with evidence of cholestatis with deranged liver function tests. Operation still indicated in children older than 3 months. Diagnosed with billiary atresia Pediatr; Indian J gastroenterology ; Evaluation of Triangular cord sign in the diagnosis of billiary atresia.

    Differential diagnosis of extrahepatic billiary atresia from neonatal hepatitis: Billiary tract disease in children.

    Ped clin north Am; Imaging of neonatal cholestatis. Technician Vitamin K Antibiotics I. Pathologist for biopsy Radiologists Nuclear medicine UTI in the presence of infection results in kidney damage and one of the common causes of chronic renal failure in adult hood. Vesico ureteric reflux may be primary due to short intramural course of ureters or it may be secondary to posterior urethral valves, Ureteroceles.

    Neurogenic bladder or it may be a part of duplex system of the kidney. During the first year of life, the male to female ratio is 3- 5: Beyond years, there is female preponderance with male to female ratio of 1: Differential diagnosis of VUR I. Obstructive Mega ureters, II. Posterior urethral valves with reflux VIII. Stones in the bladder and ureter. Prevention and counselling VUR is congenital disease either primary or secondary to congenital outlet obstructions.

    As such prevention is not possible. Presence of pelviureteric dilatation on antenatal scans needs evaluation soon after birth. However UTI secondary to VUR can be prevented by prophylactic antibiotic therapy, Periodical cultures and recognising infective episodes and treating them aggressively. Mothers must be counselled on the need for long term chemo prophylaxis and have the urine culture done every febrile episode of the child with VUR.

    Early recognition can prevent damage and scarring to the kidney , As regards the parents can be counselled that Grade I to III is likely to disappear spontaneously in most cases within a period of two to three years.

    However spontaneous disappearance Gr IV and Gr V is likely to be less but can be given a chance of Chemo prophylaxis and observation for a period of two to three years. Break through infections and fresh scars and structural abnormalities will be an indication for surgical intervention. Optimal diagnostic criteria , investigations treatment and referral criteria. Febrile episodes with anorexia , vomiting and shivering Voiding dysfunction and dysuria b.

    If the urine culture is positive c. No role for day-care d. UTI treated with appropriate oral antibiotics e.

    UTI treated by appropriate antibiotics intravenously: Sick child Based on culture and sensitivity report child needs admission. Appropriate antibiotics are chosen and administered for a period of 7 to 10 days intravenously.

    It should be followed by oral chemo prophylaxis till the reflux subsides with periodical monitoring of the urine culture especially during febrile episodes. In metro hospitals for the VUR no surgical intervention is done. Ultrasonogram done shows some structural abnormalities , should be investigated further with Intravenous urogram and sent to higher centres for intervention.

    All cases of UTI who have not been evaluated with MCU should be referred to higher centre for further evaluation and plan of management. All patients with VUR should be referred to higher centres for Radionuclide studies to see the differential renal function and asses the renal damage. Lower grades of reflux with recurrent UTI and evidence of development of new scars and anatomical abnormalities need to be referred to higher centres for management. B All cases of Gr IV and Gr V VUR should be referred to centres doing major paediatric surgical work as they do not undergo spontaneous resolution and require surgical or endoscopic management.

    Situation 2 At super specialty at metro location where higher end technology is available Investigations. Routine urine examination and culture and sensitivity Blood urea creatinine Ultrasonogram DMSA scan IVU in selected cases to exclude upper urinary tract lesions Bladder function Urodynamics studied in selected cases Other investigations such as Plasma rennin activity and Genetic studies may be required in some cases.

    Absolute indications for surgery i. Anatomic abnormalities of the bladder and VU junction j. Unresolving VU reflux k. Progressive renal injury l. Break through Pyelonephritis inspite of appropriate antibiotic prophylaxis m. Failure of renal and somatic growth Non compliance in medical management of the drug regime Treatment Primary treatment Treatment of UTI with appropriate drug with appropriate dosage and period of time.

    Type of surgery Open surgery: Endoscopic injection therapy 3 Diversion procedures like Ureterostomy and vesicostomy. Long term management will include surveillance of the child and addressing bladder dysfunction if present. Referals Even in Metro cities there are several levels of care. Surgical and endoscopic procedures should be done in institutions with proper cystoscopes for different age groups including C arm facilities and monitors to see the endoscopic procedures are necessary.

    Anaesthetist trained in paediatric anaesthesia is essential. Material for In addition to 1 advanced laboratory, fluoroscopy faclity nuclear medicine facility, Chandrakala, Department of Pediatrics, St.

    Neonatal jaundice is one of the most common neonatal problems. The most common cause of neonatal jaundice is physiologic jaundice. Although most newborns with jaundice are otherwise healthy, they need to be monitored because bilirubin is potentially toxic to central nervous system, causing bilirubin induced neuronal damage BIND.

    Chronic BIND is also known as kernicterus. Kernictrus leads to permanent neurodevelopmental handicap. Physiologic jaundice is benign and self limiting, but pathologic jaundice can cause severe hyperbilirubinemia , which if not treated appropriately can result in kernicterus g.

    For both situation of care mentioned below Neonatal jaundice: Chronic bilirubin encephalopathy Kernictrus: Chronic and permanent clinical sequelae of bilirubin toxicity Bilirubin induced neurological dysfunction BIND: Onset on day of life p. Subsides over days Preterm: All pediatric inguinal hernias require operative treatment to prevent the development of complications, such as inguinal hernia incarceration or strangulation.

    Inguinal hernia is a type of ventral hernia that occurs when an intra-abdominal structures, such as bowel or omentum, protrude through the open processus vaginalis through the inguinal canal. Sixty percent of hernias occur on the right side.

    The male-to-female ratio is estimated to be A high index of suspicion is required-especially in the high risk population of premature babies. If a child has developed a unilateral hernia, there is a potential risk of developing a hernia on the opposite side-this risk is higher in premature babies and infant girls.

    These families need to be counseled about signs and symptoms of these recurrences. History of a soft swelling in inguinal region. Gets larger when child cries, may disappear completely when the child is quietly lying down. Soft, reducible mass in the inguinal area is diagnostic.

    Even in the absence of the mass at examination, a strong history is adequate for diagnosis. No imaging studies are required. General tests towards anaesthesia fitness may be required haemoglobin, urine analysis. A strong clinical history and physical findings of inguinal hernia are indications for referral for surgery. The parents typically provide the history of a visible swelling or bulge, commonly intermittent, in the inguinoscrotal region in boys and inguinolabial region in girls.

    Usually, a simple inguinal hernia in an infant is painless. The bulge commonly occurs after crying or straining and often resolves during the night while the baby is sleeping. Patients with an incarcerated hernia generally present with a tender firm mass in the inguinal canal or scrotum. The child may be fussy, unwilling to feed, and inconsolably crying. The skin overlying the bulge may be edematous, erythematous, and discolored. The mass may only be noticeable after coughing or performing a Valsalva maneuver and it should be reduced easily.

    Occasionally, the examining physician may feel the loops of intestine within the hernia sac. In girls, feeling the ovary in the hernia sac is not unusual; it is not infrequently confused with a lymph node in the groin region. In boys, palpation of both testicles is important to rule out an undescended or retractile testicle. Transillumination has been advocated as a means of distinguishing between the presence of a sac filled with fluid in the scrotum hydrocele and the presence of bowel in the scrotal sac.

    However, in cases of inguinal hernia incarceration, transillumination may not be beneficial because any viscera that are distended and fluid-filled in the scrotum of a young infant may also transilluminate. Its routine use is unnecessary. It is indicated when presentation and examination suggest a diagnosis other than hernia or hydrocele. An enlarged inguinal lymph node can mimic an incarcerated inguinal hernia.

    Diagnostic laparoscopy may rarely be required for determining the presence of an inguinal hernia. It is used only in the following: Surgical treatment can be either open or laparoscopic.

    Inguinal hernias do not spontaneously heal and must be surgically repaired because of the ever-present risk of incarceration. Repair is usually planned as an elective procedure as soon as possible after diagnosis. If successful, the operation is performed after hours to allow local oedema to settle down. If reduction is unsuccessful, or if there is clinical evidence of inflammation as evidenced by pain, redness, edema of skin on hernia emergency exploration and hernia repair is necessary.

    Hydroceles without hernia in neonates: This is the only exception in which surgical treatment may be delayed. Repair of hydroceles in neonates without the presence of hernia is typically delayed for 12 months because the connection with the peritoneal cavity via the processus vaginalis may be very small and may have already closed or be in the process of closing.

    If the hydorcoele persists after this observation period, operative repair is indicated and appropriate. Postpone the operation in the event of upper respiratory tract infection,otitis media, or significant rash in the groin. FOLLOW UP No specific limitations are indicated once the diagnosis of an inguinal hernia has been established; however, following operative repair, avoidance of major physical activity for 1 week is recommended.

    After that time, the patient is allowed to participate in physical activities eg, sports, swimming, running. Children younger than 5 years are likely to recover extremely quickly from surgery; they are typically capable of returning to their normal level of activities within hours of surgery.

    Optimal Standards of Treatment in Situations where technology and resources are limited a. Similar generic diagnostic criteria apply. A typical history and physical finding are adequate for diagnosis. Investigations are not required other than for anaesthetic purposes. Rarely, ultrasonography and diagnostic laparoscopy may be indicated c. Treatment is surgery -herniotomy operation that aims at ligating the patent processus vaginalis at the internal ring after reduction of contents into the abdomen b.

    Surgery is indicated if hydrocoele persists beyond the 2nd year and if it is rapidly growing is size. All hernia and hydrocoele repairs in infants and children MUST be performed by a qualified pediatric surgeon.

    Standard Operating procedure a. Outpatient care is adequate for diagnosis and follow up in most children ii. Clinical evaluation usually sufficient to diagnose c. A child with a hernia needs referral to a higher centre if: At Super Specialty Facility in Metro location where higher-end technology is available Doctor makes a clinical diagnosis, counsels the family and plans surgery- a pediatric surgeon performs the surgery b.

    Surg Clin North Am. Inguinal and umbilical hernia repair in infants and children. Laparoscopic approach to incarcerated and strangulated inguinal hernias. Neonatal cholestatis is a pathological condition in the newborn where in bile flow from the liver is reduced. Neonatal Cholestasis Syndrome NCS includes a wide spectrum of clinical conditions ranging from congenital malformations of the hepatobiliary tree, infections, inborn errors of metabolism to some of the recently identified clinical conditions with or without genetic predilection.

    Most of these disorders have linkage with insults during antenatal, natal and postnatal periods. The average age of presentation to a specialized center is 3. If the previous sibling has had liver disease antenatal counselling and referral for further evaluation may be necessary. Optimal Standards of Treatment in Situations where technology and resources are limited Standard Operating procedure 4.

    Resuscitation if required, 5. Correction of Hypoglycemia 6. Administration of Vitamin K 0. Child needs admission if 1. Baby who is clinically well, feeding well and has no evidence of hypoglycemia or coagulopathy can be investigated as an outpatient No role of day care admission.

    All workup at this level must be completed by 48 hours 1. Clinically unwell, poor feeding, poor weight gain 3. GGT is raised in all cases of cholestasis except in one of the bile acid synthetic defects. Serum albumin does not fall till late. None of the biochemical tests are of deciding value and at best reflect the degree of damage to liver. Tests directed towards infective and metabolic causes: Role of Hida Scan Hepatobiliary scintigraphy, after a 5 day priming with phenobarbitone,is useful.

    Excretion of the radio-tracer into the gut rules out biliary atresia. However, the converse is not true and absence of gut excretion of radiotracer requires further evaluation.

    Coagulopathy and ascitis are contraindications for percutaneous liver biopsy. Spontaneous perforation of bile ducts 6. Avoid hyper- vitaminosis as it can enhance fibrosis. If the child has rickets give a dose of 60, IU. Perform prothombin time PT monthly. Administer injectable vitamin K if PT is prolonged. Referral criteria for a specialist centre: Any case of neonatal cholestasis as defined by above parameters with deranged liver function tests to be referred to tertiary centre for further management.

    Child needs to be referred to a specialist pediatric liver unit if, 1. Evidence of progressive liver failure 2. Evidence of complications such as portal hypertension, SBP, Respiratory distress, pathological fractures. Failure of Kasai operation Evidence of liver cirrhosis in biopsy Jaundice not cleared by 2 months after surgery 4. Considerations for liver transplant Situation 2: Referred cases from secondary centres or any newborn with evidence of cholestatis with deranged liver function tests.

    Operation still indicated in children older than 3 months. Diagnosed with billiary atresia Pediatr; Indian J gastroenterology ; Evaluation of Triangular cord sign in the diagnosis of billiary atresia. Differential diagnosis of extrahepatic billiary atresia from neonatal hepatitis: Billiary tract disease in children. Ped clin north Am; Imaging of neonatal cholestatis.

    Technician Vitamin K Antibiotics I. Pathologist for biopsy Radiologists Nuclear medicine UTI in the presence of infection results in kidney damage and one of the common causes of chronic renal failure in adult hood. Vesico ureteric reflux may be primary due to short intramural course of ureters or it may be secondary to posterior urethral valves, Ureteroceles. Neurogenic bladder or it may be a part of duplex system of the kidney.

    During the first year of life, the male to female ratio is 3- 5: Beyond years, there is female preponderance with male to female ratio of 1: Differential diagnosis of VUR I.

    Obstructive Mega ureters, II. Posterior urethral valves with reflux VIII. Stones in the bladder and ureter. Prevention and counselling VUR is congenital disease either primary or secondary to congenital outlet obstructions. As such prevention is not possible.

    Presence of pelviureteric dilatation on antenatal scans needs evaluation soon after birth. However UTI secondary to VUR can be prevented by prophylactic antibiotic therapy, Periodical cultures and recognising infective episodes and treating them aggressively. Mothers must be counselled on the need for long term chemo prophylaxis and have the urine culture done every febrile episode of the child with VUR.

    Early recognition can prevent damage and scarring to the kidney , As regards the parents can be counselled that Grade I to III is likely to disappear spontaneously in most cases within a period of two to three years. However spontaneous disappearance Gr IV and Gr V is likely to be less but can be given a chance of Chemo prophylaxis and observation for a period of two to three years. Break through infections and fresh scars and structural abnormalities will be an indication for surgical intervention.

    Optimal diagnostic criteria , investigations treatment and referral criteria. Febrile episodes with anorexia , vomiting and shivering Voiding dysfunction and dysuria b. If the urine culture is positive c. No role for day-care d. UTI treated with appropriate oral antibiotics e.

    UTI treated by appropriate antibiotics intravenously: Sick child Based on culture and sensitivity report child needs admission. Appropriate antibiotics are chosen and administered for a period of 7 to 10 days intravenously. American Academy of Neurology". Retrieved 1 June Int J Rheum Dis. Archived from the original on 15 March Retrieved 15 March The Cochrane Database of Systematic Reviews. Genetic aspects of fibromyalgia syndrome".

    American College of Rheumatology. Archived from the original on 17 March Mayo Clinic Proceedings Review. Handbook of Clinical Neurology. Expert Review of Neurotherapeutics. Neurobiological foundations for EMDR practice. Journal of the American Osteopathic Association.

    Archived from the original on 4 January Retrieved 26 August Curr Pain Headache Rep. Retrieved 21 May Best Pract Res Clin Rheumatol. Catherine 1 October A systematic review with meta-analysis". A Systematic Review and Meta-Analysis".

    A study with single-voxel magnetic resonance spectroscopy". Correlation With Clinical Features". Longitudinal data on an adult female population in Norway". Curr Med Res Opin. Clinical and Experimental Rheumatology. Archived PDF from the original on 6 November The American Journal of Medicine. Etiology, Pathogenesis, Diagnosis, and Treatment". Pain Research and Treatment. Nature Clinical Practice Rheumatology.

    Archived from the original on 8 April Retrieved 4 May Archived from the original on 17 June Retrieved 17 May Archived from the original on 14 October Jon; Winfield, John B.

    Journal of Clinical and Experimental Neuropsychology. Am J Med Review. Indications for a correct diagnosis". World J Gastroenterol Review. Systematic review, meta-analysis and guideline" PDF. Archived from the original PDF on 16 February Archived PDF from the original on 23 May Food and Drug Administration. Archived from the original on 21 February Retrieved 14 January Archived PDF from the original on 22 February Retrieved 30 May Andrew; Wiffen, Philip J. The Cochrane Database of Systematic Reviews Cochrane Database Syst Rev.

    The Cochrane Database of Systematic Reviews 4: Patterns of use of opioids in patients with fibromyalgia In: Seminars in Arthritis and Rheumatism. Archived from the original on 1 April Rheumatic Diseases Clinics of North America. Cochrane Database of Systematic Reviews 6: Cochrane Database of Systematic Reviews.

    Management strategies for primary care providers". The International Journal of Clinical Practice. Journal of the American Medical Association.

    American Journal of Medicine. A meta-analysis of randomized controlled clinical trials". American Journal of Therapeutics. Current Opinion in Rheumatology. Archived from the original on 20 February Retrieved 2 February Archived from the original on 29 September Retrieved 6 January Archived from the original on 22 June Archived from the original on 13 December Archived from the original on 12 April An emerging but controversial condition".

    Fibromyalgia

    Feature 4: The Strange World of Ketamine While the stimulants are often inhaled or ingested orally they are also injected. Initiation into Cannabis Use Melbourne, including Collingwood/Fitzroy, the Melbourne CBD, St Kilda. Calcium channel blockers (CCB). .. Oral and new antidiabetic drugs . Drugs used to treat oral mucosal and periodontal disease. mushrooms), LSD (lysergic acid diethylamide), mescaline, and ketamine. Dependency is relaxing properties and cannabidiol (CBD) acts as an anticonvulsant. pills/powders/drugs smoked plus ketamine since /07 interviews and 9 Sativex is formulated as an oral spray containing mg THC and mg CBD. Table gives the resulting unit cost estimates, which range from £ for a.

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    Feature 4: The Strange World of Ketamine While the stimulants are often inhaled or ingested orally they are also injected. Initiation into Cannabis Use Melbourne, including Collingwood/Fitzroy, the Melbourne CBD, St Kilda.

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