By F. Jaffar. University of North Carolina at Greensboro.

Spiritu- aged her and her pain was controlled until she ality and religion cheap zudena 100mg, is a comfort and most women died quality 100 mg zudena. However buy 100 mg zudena visa, many gynecolo- Thus if you are going to be able to address the gists and oncologists insist on providing invasive many faceted areas of palliative care order 100mg zudena visa, it is more im- therapy, causing pain and distress, up to the last portant to be a special person than to be a special- (Box 1). We need to be willing to give time to our the terminally ill patient taking into account the patient and even time away from the patients when prognosis for life or for time left. If time was short, you learn what is needed in your part of this world. It is heart However every country, every tribe, every family, breaking to see how many women are subjected to is different. Chemotherapy and radiotherapy are often only available to the very rich and sometimes not at all. The World Health Organization (WHO) defines palliative care as2: Principles of palliative care ‘Palliative care is an approach that improves 1. The comfort the quality of life of patients and their families and peace of the patient is our priority. The facing the problem associated with life- patient is our guest and will take part in deci- threatening illness, through the prevention sion-making with the physician and the team and relief of suffering by means of early iden- up to her death. The care of the patient is ho- tification and impeccable assessment and listic, including addressing all of the needs of treatment of pain and other problems, physi- patient and family. The palliative care physi- cal, psychosocial and spiritual. Palliative care cian may have to interact with oncologists, provides relief from pain and other distressing radiotherapists, surgeons and others, ensuring symptoms; affirms life and regards dying as a that investigations and management decisions normal process; intends neither to hasten nor are made with the comfort of the patient al- postpone death; integrates the psychological ways in mind. Some investigations and treat- and spiritual aspects of patient care. How- • We are aiming at the best possible quality of life ever, in less-resourced settings, other options for our patient. Wherever possible the physician works with a problems, physical, psychosocial, cultural and team. In less-resourced settings a nurse is often spiritual. The team is non- • Our care and approach indicates that we affirm bureaucratic and cares for each other while life (while being prepared to tell the truth) and I sharing information with confidentiality, for myself regard death as a normal process (cure is the good of the patient and family. Teaching others is essential in resource-limited • Acknowledge that while not curing my patient, situations where palliative care is new. We recognize that there is a need for all of us to breast is number 1 in Nigeria. In most countries in meet the needs of our patients and families. We Africa, these are similar in incidence and they are therefore network with other organizations, the main cancers we deal with. Cancer of the ovary and respect them without being in rivalry situa- is less common but brings a poor prognosis and tions. Recent research into pain and symptom terrible suffering. In sub-Saharan Africa in particu- control has brought palliative care to a specialty lar, the suffering of cancer in women may be com- level under medicine. Early detection and methods for early detection are in their infancy, such as cervical screening. Remembering that in Physical pain Uganda 57% and in Ethiopia 85% of sick people never see a health worker, we can see that many are Physical pain can be soul destroying not only to the lying in the villages waiting for death in terrible patient but also to the family. Children who have 408 Palliative Care witnessed the suffering of a parent have memories damage to an organ, which is stretched or inflamed. Families may ask for The pain is difficult to locate and may be indicated admission or place the patient in an outhouse far in a wider area than the injury. It Thus, diagnosing physical pain, and treating and is due to the release of prostaglandins at the nerve removing such pain opens the door to the other endings. Non-steroidal anti-inflammatory drugs facets of palliative care. While in severe pain, (NSAIDS) and corticosteroids act by neutralizing neither the patient nor the family can make plans, the prostaglandins and are often referred to as say their farewells or come to peace with their anti-prostaglandins. Thus, understanding pain Medications from each step are usually available and managing it is essential to palliative care. However lieving pain opens the door to the holistic diagnosis the resources of the patient and family now come and management of other aspects. Few countries have medications afford- Dame Cicely Saunders , founder of the Modern able to all or free to all. She de- In cancer, analgesics must be given so that the fined this concept of ‘total pain’ as the suffering that pain never returns. This means that another dose is encompasses all of a person’s physical, psychologi- cal, social, spiritual and practical struggles (Figure 1). Some basics on pain and treatment of pain in resource-poor settings ‘Pain is what the patient says hurts’. Other scien- tific definitions cannot get across the importance of this clinical concept. All pain needs our attention and impeccable assessment. Somatic pain is felt when the nerve fibers from the site of the injury to the brain are intact. Neuro- pathic pain indicates damage to a nerve and inter- ruption or alteration of transmission (Figure 2). Peripheral pain may be from inflammation on the skin or the joints. Visceral pain is pain arising from Physical Total Social Emotional Pain Spiritual Cultural Figure 3 The analgesic ladder. Adapted from EPEC™ Figure 1 The concept of ‘total pain’ with permission 409 GYNECOLOGY FOR LESS-RESOURCED LOCATIONS given at the time relating to the half-life of the sub- stance (Figures 4 and 5) but, if this is not working, the timing may have to be adjusted. The aim of pain control is to have a patient who is alert, able to work, think and enjoy life without side-effects and without fear of the pain returning. Figure 6 shows the half-life of selected analgesic drugs. Figure 7 shows diagrammatically how important it is to administer analgesic drugs by the clock in a dose that does not cause drowsiness and does not allow the pain to return. We must take into account the patient’s responsibility and our own, to observe Figure 5 Half-life of drugs according to method of administration. Adapted from EPEC™ with permission individual needs, when taking her own medicines. The analgesic ladder The analgesic ladder (Figure 3) was first recom- mended by WHO in 1986. It is important to follow up pain and re-assess it until from a high score (on STEP 1 0–5) the pain is at 0. Various techniques are used to ■ Aspirin 4 hours measure pain improvement and the commonest ■ Paracetamol 4 hours one is shown in Figure 8. Paracetamol is the ■ Codeine 4 hours safest and is effective in many patients. Step 2 is usually available as codeine or dihydrocodeine. Both are ■ Morphine solution 4 hours expensive and have a ceiling. For cancer patients, ■ MST 12 hours most are now leaving out this step and going from Figure 6 Half-life of selected analgesic drugs Figure 4 Metabolic pathways Figure 7 Importance of administering drugs by the clock 410 Palliative Care five to six times more expensive in some countries and it is up to each country to have a watch-dog on prices, if those in need are to be relieved of pain. It is very simple to make as it is a matter of mixing the morphine with water, a dye and a pre- servative. Thus it can be made in a simple pharmacy if the ingredients are available, as well as an accurate scale to weigh the morphine powder and clean filtered water. In Uganda we have used recycled Figure 8 A visual analog scale of 0–5 is used to identify water bottles and this has proved to be safe and pain, with 0 ‘I do not have any pain’ to 5 ‘My pain could affordable. The fingers of the hand can also be used to to severity of the pain and the condition of the indicate 0–5. The pain should be less at each visit patients at 2. If a patient is in severe pain, an initial dose of 10–20mg may be given.

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Nosocomial bacterial pneumonia in HIV-infected patients: risk factors for adverse outcome and implications for rational empiric antibiotic therapy zudena 100 mg low price. Pneumonia in HIV-infected persons: increased risk with cigarette smoking and treatment interruption zudena 100mg fast delivery. Epidemiologic changes in bacteremic pneumococcal disease in patients with human immunodeficiency virus in the era of highly active antiretroviral therapy purchase 100mg zudena with mastercard. Impact of prior pneumococcal vaccination on clinical outcomes in HIV- infected adult patients hospitalized with invasive pneumococcal disease generic 100mg zudena free shipping. A Clinical Predictor Score for 30-Day Mortality among HIV-Infected Adults Hospitalized with Pneumonia in Uganda. Does enfuvirtide increase the risk of bacterial pneumonia in patients receiving combination antiretroviral therapy? Bacterial community-acquired pneumonia in HIV-infected patients. Risk factors and clinical characteristics associated with hospitalization for community-acquired bacterial pneumonia in HIV-positive patients according to the presence of liver cirrhosis. Effectiveness of polysaccharide pneumococcal vaccine in HIV-infected patients: a case-control study. Prospective study of etiologic agents of community-acquired pneumonia in patients with HIV infection. Ambulant erworbene untere Atemwegsinfektionen/ambulant erworbene Pneumonien bei erwachse- nen Patienten. Empfehlungen einer Expertengruppe der Paul-Ehrlich-Gesellschaft für Chemotherapie e. Chemotherapie Journal 2000, 1:3-23 384 AIDS Cryptosporidiosis Cryptosporidiosis is a parasitic intestinal disease with fecal-oral transmission. It is mainly caused by the protozoon Cryptosporidium parvum (two genotypes exist, geno- type 1 is now also known as C. First described in 1976, cryp- tosporidia are among the most important and most frequent causes of diarrhea world- wide. Important sources of infection for this intracellular parasite include animals, contaminated water and food. While diarrhea almost always resolves within a few days in otherwise healthy hosts or in HIV+ patients with CD4 counts greater than 200 cells/µl, cryptosporidiosis is often chronic in AIDS patients. Particularly in severely immunocompromised patients (<50 CD4 T cells/µl), diarrhea may become life-threatening due to water and electrolyte loss (Colford 1996). Only chronic, and not acute, cryptosporidiosis is AIDS-defining. Signs and symptoms The typical watery diarrhea can be so severe that it leads to death as a result of elec- trolyte loss and dehydration. Up to twenty bowel movements a day are not uncom- mon. Tenesmus is frequent, along with nausea and vomiting. Additionally, the biliary ducts may occasionally be affected with the elevation of biliary enzymes. Diagnosis When submitting stool samples, the laboratory should be informed of the clinical suspicion. If the lab is experienced and receives the correct information, usually just one stool sample is sufficient for detection. In contrast, antibodies or other diagnostic tests are not helpful. The dif- ferential diagnosis should include all diarrhea-causing pathogens. Treatment No specific treatment has been established to date. Diarrhea is self-limiting with a good immune status; therefore, poor immune status should always be improved with ART – and this often leads to resolution (Carr 1998, Miao 2000). To ensure absorp- tion of antiretroviral drugs, symptomatic treatment with loperamide and/or opium tincture, a controlled drug prescription, at its maximum dosage, is advised. If this is unsuccessful, then treatment with other anti-diarrheal medications, perhaps even sandostatin, can be attempted. Sufficient hydration is necessary and infusions may even be required. Recent reviews confirm the absence of evidence for effective agents in the manage- ment of cryptosporidiosis (Abubakar 2007, Pantenberg 2009). We have observed good results with the antihelminthic agent nitazoxanide (Cryptaz). Nitazoxanide proved to be effective in a small, randomized study (Rossignol 2001). In 2005 it was licensed in the US for treatment of cryptosporidia-associated diarrhea in immunocompetent patients. Nitazoxanide is not approved for AIDS patients and showed no effects in a double-blind randomized study in HIV+ children with cryptosporidia (Amadi 2009). Rifaximine (Xifaxan, 200 mg) is a nonabsorbed rifampicin derivative, already licensed in the US as an anti-diarrheal. The first data with AIDS patients are very promising (Gathe 2008). Opportunistic Infections (OIs) 385 Paromomycin (Humatin) is a nonabsorbed aminoglycoside antibiotic and has shown favorable effects on diarrhea in small uncontrolled studies (White 2001). In one double-blind randomized study, however, there was no advantage over placebo (Hewitt 2000). Potentially, there is an effect in combination with azithromycin (Smith 1998). Treatment/prophylaxis of cryptosporidiosis (daily doses) Acute therapy Symptomatic Loperamide + Loperamide 1 cap. The importance of good hygiene and not drinking tap water should be emphasized to patients, at least in countries with limited access to clean, adequate drinking water. Contact with human and animal feces should be avoided. The tendency for patients to become ill during the summer months can often be linked to swimming in rivers or lakes. In hospitals and other medical facilities, the usual hygienic measures, such as wearing gloves, are adequate. However, they should not be put in the same room with other significantly immunocompromised patients. References Abubakar I, Aliyu SH, Arumugam C, Usman NK, Hunter PR. Treatment of cryptosporidiosis in immunocompro- mised individuals: systematic review and meta-analysis. Effect of nitazoxanide on morbidity and mortality in Zambian children with cryptosporidiosis: a randomised controlled trial. High dose prolonged treatment with nitazoxanide is not effective for cryp- tosporidiosis in HIV positive Zambian children: a randomised controlled trial. Treatment of HIV-1 associated microsporidiosis and cryp- tosporidiosis with combination antiretroviral therapy. Factors related to symptomatic infection and survival. Resolution of severe cryptosporidial diarrhea with rifaximin in patients with AIDS. Paromomycin: No more effective than placebo for treatment of cryp- tosporidiosis in patients with advanced HIV infection. Possible effectiveness of clarithromycin and rifabutin for cryp- tosporidiosis chemoprophylaxis in HIV disease. Eradication of cryptosporidia and microsporidia following suc- cessful antiretroviral therapy.

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