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About 20% of fevers in childhood have no apparent cause. A small, but significant number of these children may have a seroius bacterial infection. Fever without a focus of infection is an acute febrile illness with rectal temperature of 38 degrees C or higher in children younger than 36 months, without localizing signs or symptoms. ⋯ In this article, practical recommendations for medical care of febrile children 0-36 months of age are given, bearing in mind children's age, clinical presentation (toxic manifestations) and risk for serious bacterial infection (sepsis, meningitis, pneumonia, urinary tract infection...). Toxic appearance is a clinical presentation characterized by lethargy, poor perfusion, marked hypo/hyperventilation and cyanosis. All febrile children under 36 months of age, who are appearing toxic, require hospitalization, evaluation for sepsis and administration of empiricial antibiotic therapy. All febrile neonates, however, must be hospitalized; cultures of blood, urine and spinal fluid should be taken and empirical antibiotic therapy administered immediately. Febrile infants, 28 to 90 days of age, need to be evaluated in order to determine whether they are in the low-risk group for serious bacterial infections (Rochester Criteria). Yale Observation Scale is recommended to assess febrile children aged 3-36 months, and the risk of occult bacteriemia. Febrile children, 3-36 months of age who appear well, with temperature of less than 39 degrees C without focus, should be closely followed up without laboratory tests and antibiotics and 2-3 days later reexamined. In febrile children, 3-36 months old, with temperature of 39 degrees C and above, without toxic manifestations, blood culture should be taken and ceftriaxone 50 mg/kg/in a single dose should be given, if leukocyte count is 15000/mm3 or absolute neutrophil count is over 10.000/mm3.
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Affection of the abdominal organs with sarcoidosis is a part of the generalized granulomatous diseases with clinical manifestations that vary depending on the affected organ. ⋯ Examinations of abdominal organ involvement should be a standard procedure in each patient affected with sarcoidosis.
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Neuropathic pain in cancer patients requires a focused clinical evaluation based on knowledge of common neuropathic pain syndromes. ⋯ Treatment of neuropathic pain remains a challenge for clinicians, because there is no accepted algorithm for analgesic treatment of neuropathic pain. Pharmacotherapy is considered to be the first line therapy. Opioids combined with non-steroidal antiinflammatory drugs are warranted. If patient is relatively unresponsive to an opioid, a trial with adjuvant analgesics might be considered. Tricyclic antidepressants might be selected for patients with continuous dysesthesia, and anticonvulsants might be used if the pain is predominanty lancinating or paroxysmal. The complexity of neuropathic syndromes and underlying etiologic mechanisms warrant clinical trials to determine appropriate treatment.
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Postoperative nausea and vomiting (PONV) and pain are the most common complaints following anesthesia and surgery, and due to negative emotional impact on patients, they cause prolonged postoperative recovery. The incidence of PONV is 20-30% during the first 24 h after anesthesia. Both peripheral and central mechanisms are involved in control of emesis. ⋯ Many factors associated with anesthesia and surgery may affect PONV: patient's age and sex, history of PONV after pervious anesthesia, administration of antiemetics prior to operation, type and duration of operation, type of premedication, induction agent, maintenance agent, reversal of muscle relaxation, treatment of postoperative pain and movement of patients. ANTAGONISTS OF 5-HYDROXYTRYPTAMINE-3 (5-HT3) RECEPTORS: Ondansetron is a competitive serotonin type 3 receptor antagonist important in prevention of PONV. However, if 5-HT 3 receptor antagonists are effective against nausea and vomiting after a variety of anesthetic and surgical procedures, then at last we may have the key to the mechanism of PONV. Prophylaxis with a combination of antiemetic drugs is more effective in prevention of PONV.
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There are two isomers of ketamine: S(+) ketamine and R(-) ketamine. Effects of this drug are mediated by N-methyl-D-aspartate (NMDA), opioid and muscarinic receptors. ⋯ Combination of ketamine and midazolam can be very useful and safe for sedation and pain relief in intensive care patients, especially during ventilator management. Ketamine may be the anesthetic of choice for painful procedures in intensive care units.