2. Diabetes in Children
Type 1 DM is the most common type in children,
accounting for two thirds of new cases in children of
all ethnic groups. It is one of the most common
chronic childhood diseases, occurring in 1 in 350
children by age 18; the incidence has recently been
increasing, particularly in children < 5 yr. Although
type 1 can occur at any age, it typically manifests
between age 4 yr and 6 yr and between 10 yr and
14 yr.
3. In type 1 DM, the pancreas produces
no insulin because of autoimmune destruction of
pancreatic beta-cells, possibly triggered by an
environmental exposure in genetically susceptible
people. Close relatives are at increased risk of DM,
with overall incidence 10 to 13% (30 to 50% in
monozygotic twins). Children with type 1 DM are at
higher risk of other autoimmune disorders,
particularly thyroid disease and celiac disease.
Inherited susceptibility to type 1 DM is determined
by multiple genes (> 60 risk loci have been
identified). Susceptibility genes are more common
among some populations and explain the higher
prevalence of type 1 DM in certain ethnic groups
(eg, Scandinavians, Sardinians).
4. In type 1 DM, lack of insulin causes
hyperglycemia and impaired glucose utilization
in skeletal muscle. Muscle and fat are then
broken down to provide energy. Fat breakdown
produces ketones, which cause acidemia and
sometimes a significant, life-threatening
acidosis (diabetic ketoacidosis [DKA]).
6. Type 1 Diabetes in Young Children
Epidemiological Trends
Type 1 diabetes has increased in incidence
and prevalence during the late 20th and early
21st centuries.
During this time period there has been a shift
towards a younger age of onset.
6
7. Challenges of Caring for Young Children With
Diabetes
Unpredictable eating patterns
Unpredictable activity patterns
Hypoglycemic unawareness
Periods of rapid growth
Susceptibility to communicable illness
Evolving understanding of what diabetes is
and how it impacts identity
Need for age-appropriate developmental
experiences
8
10. Unpredictable Activity Patterns
Hypoglycemia
Hypoglycemia is the main risk factor when children are
active
Insulin cannot be turned off or limited once it is
delivered
Young children are unaware of symptoms of
hypoglycemia, and older children miss symptoms when
focused on activity
Young children are less likely to experience a blood
glucose raising adrenaline response during vigorous
activity
11. Unpredictable Activity Patterns
Hypoglycemia
Too little carbohydrate to sustain prolonged
activity
Too much insulin available or “on board”
Unplanned activity
Swimming and sledding
12. Unpredictable Activity Patterns
Hyperglycemia
Too little insulin before during, and/or after
exercise
Too much carbohydrate consumed before or
during exercise
Unplanned naps
Rainy days
14. Unpredictable Exercise Patterns
Carbohydrate Adjustment
Estimate 5-15 grams of extra carbohydrate for every 30
minutes of vigorous activity depending on body weight and
intensity of activity
Add fat and protein to help carbohydrate last longer during
activity
Decrease carbohydrate and fat content of meals and
snacks on low activity days if child is not underweight
16. Hypoglycemic Unawareness
Increase blood glucose monitoring during and
after activity
Increase blood glucose monitoring during
episodes of illness
Consider use of continuous glucose
monitoring device in consultation with
diabetes care providers
18. Periods of Rapid Growth
Adequate insulin is needed to utilize carbohydrate for
growth. Children with diabetes who do not get enough
insulin will grow and gain more slowly than would be
predicted by their genetics.
Children who have frequent episodes of low blood sugar
and/or whose caretakers are unusually frightened by
hypoglycemia may gain excess weight
Hormones that accompany rapid growth cause increased
insulin resistance
Growth hormone is usually active during periods of deep
sleep causing a young child to have different daily
patterns of insulin need than an older child has
20. Susceptibility to Communicable Illness
Children’s day to day activities bring them into contact
with a variety of viral and bacterial illnesses
Even mild viruses such as colds can increase insulin
requirements
Gastrointestinal illnesses with vomiting and diarrhea
can result in poor absorption of carbohydrate and
dehydration causing blood glucose to fall and ketones
to rise.
Management of “sick days” requires frequent blood
glucose and ketone monitoring, assessment of fluid
and carbohydrate intake, and regular contact the child’s
diabetes team as needed.
26
21. Susceptibility to Communicable Illness
Be sure you have a copy of and understand your
diabetes team’s sick day protocol.
Check your supply and the expiration date of
ketone strips regularly.
Use blood ketone strips for assessing ketones on
sick days if possible.
Discuss when use of “mini-glucagon” injections
might be use with your diabetes team.
27
22.
23. DEFINITION:
Acute rheumatic fever is a systemic disease
of childhood ,often recurrent that follows
group A beta hemolytic streptococcal infection
It is a diffuse inflammatory disease of
connective tissue primarily involving heart,
blood vessels, joints, subcutaneous tissue
and CNS
25. Epidemiology
Ages 5-15 yrs are most susceptible
Rare <3 yrs
Girls>boys
Environmental factors--over crowding,
poor sanitation, poverty,
Incidence more during fall ,winter & early
spring
26. Pathogenesis
Delayed immune response to infection
with group A beta hemolytic
streptococci.
After a latent period of 1-3 weeks,
antibody induced immunological
damage occur to heart valves, joints,
subcutaneous tissue & basal ganglia of brain.
27. Pathologic Lesions
Fibrinoid degeneration of connective tissue,
inflammatory edema, inflammatory cell
infiltration & proliferation of specific cells
resulting in formation of Ashcoff nodules,
resulting in-
-Pancarditis in the heart
-Arthritis in the joints
-Ashcoff nodules in the subcutaneous
tissue
-Basal gangliar lesions resulting in chorea
28. Clinical Features
Flitting & fleeting migratory polyarthritis, involving major
joints
Commonly involved joints-knee, ankle, elbow & wrist
Occur in 80%,involved joints are exquisitely tender
In children below 5 yrs arthritis usually mild but carditis
more prominent
Arthritis do not progress to chronic disease
1.Arthritis
29. Clinical Features
Manifest as pancarditis(endocarditis, myocarditis
and pericarditis),occur in 40-50% of cases
Carditis is the only manifestation of rheumatic fever that
leaves a sequelae & permanent damage to the organ
Valvulitis occur in acute phase
Chronic phase- fibrosis,calcification & stenosis of heart
valves(fishmouth valves)
2.Carditis
30. Clinical Features (Contd)
Occur in 5-10% of cases
Mainly in girls of 1-15 yrs age
May appear even 6/12 after the attack of rheumatic
fever
Clinically manifest as-clumsiness, deterioration of
handwriting, emotional lability or grimacing of face
Clinical signs- pronator sign, jack in the box sign ,
milking sign of hands
3.Sydenham Chorea
31. Clinical Features
Occur in <5%.
Unique,transient,serpiginous-looking lesions of 1-2
inches in size
Pale center with red irregular margin
More on trunks & limbs & non-itchy
Worsens with application of heat
4.Erythema Marginatum
32. Clinical Features (Contd)
Occur in 10%
Painless, pea-sized, palpable nodules
Mainly over extensor surfaces of
joints,spine,scapulae & scalp
Associated with strong seropositivity
5.Subcutaneous nodules
33. Clinical Features
Fever-(up to 101 degree F)
Arthralgia
Pallor
Anorexia
Loss of weight
Other features (Minor features)
34. Laboratory Findings
High ESR
Anemia, leukocytosis
Elevated C-reactive protein
ASO titer >200 Todd units.
(Peak value attained at 3 weeks, then comes
down to normal by 6 weeks)
Throat culture-B H streptococci
35. Laboratory Findings (Contd)
ECG- prolonged PR interval, 2nd or 3rd
degree blocks,ST depression, T inversion
2D Echo cardiography- valve edema,mitral
regurgitation, LA & LV dilatation, and
decreased contractility
05/05/1999
41
36. Treatment
Step I - primary prevention
(eradication of streptococci)
Step II - anti inflammatory treatment
(aspirin,steroids)
Step III- supportive management &
management of complications
Step IV- secondary prevention
(prevention of recurrent attacks)
05/05/1999
Dr.Said Alavi
43
37. 05/05/1999
Dr.Said Alavi
44
STEP I: Primary Prevention of Rheumatic Fever
(Treatment of Streptococcal Tonsillopharyngitis)
Agent Dose Mode Duration
Benzathine penicillin G 600 000 U for patients Intramuscular Once
27 kg (60 lb)
1 200 000 U for patients >27 kg
or
Penicillin V Children: 250 mg 2-3 times daily Oral 10 d
(phenoxymethyl penicillin) Adolescents and adults:
500 mg 2-3 times daily
For individuals allergic to penicillin
Erythromycin: 20-40 mg/kg/d 2-4 times daily Oral 10 d
Estolate (maximum 1 g/d)
or
Ethylsuccinate 40 mg/kg/d 2-4 times daily Oral 10 d
(maximum 1 g/d)
Recommendations of American Heart Association
38. Arthritis only Aspirin 75-100
mg/kg/day,give as 4
divided doses for 6
weeks
(Attain a blood level 20-
30 mg/dl)
Carditis Prednisolone 2-2.5
mg/kg/day, give as two
divided doses for 2
weeks
Taper over 2 weeks &
while tapering add
Aspirin 75 mg/kg/day
for 2 weeks.
Continue aspirin alone
100 mg/kg/day for
another 4 weeks
Step II: Anti inflammatory treatment
Clinical condition Drugs
39. Bed rest
Treatment of congestive cardiac failure: -
digitalis,diuretics
Treatment of chorea:
-diazepam or haloperidol
Rest to joints & supportive splinting
3.Step III: Supportive management &
management of complications
40. 05/05/1999
Dr.Said Alavi
47
STEP IV : Secondary Prevention of Rheumatic Fever
(Prevention of Recurrent Attacks)
Agent Dose Mode
Benzathine penicillin G 1 200 000 U every 4 weeks* Intramuscular
or
Penicillin V 250 mg twice daily Oral
or
Sulfadiazine 0.5 g once daily for patients 27 kg (60 lb Oral
1.0 g once daily for patients >27 kg (60 lb)
For individuals allergic to penicillin and sulfadiazine
Erythromycin 250 mg twice daily Oral
*In high-risk situations, administration every 3 weeks is justified and
recommended
Recommendations of American Heart Association
41. 05/05/1999
Dr.Said Alavi
48
Duration of Secondary Rheumatic Fever
Prophylaxis
Category Duration
Rheumatic fever with carditis and At least 10 y since last
residual heart disease episode and at least until
(persistent valvar disease*) age 40 y, sometimes lifelong
prophylaxis
Rheumatic fever with carditis 10 y or well into adulthood,
but no residual heart disease whichever is longer
(no valvar disease*)
Rheumatic fever without carditis 5 y or until age 21 y,
whichever is longer
*Clinical or echocardiographic evidence.
Recommendations of American Heart Association
42. Prognosis
Rheumatic fever can recur whenever the
individual experience new BH streptococcal
infection, if not on prophylactic medicines
Good prognosis for older age group & if no
carditis during the initial attack
Bad prognosis for younger children & those
with carditis with vulvar lesions
44. Introduction
Juvenile rheumatoid arthritis (JRA), is the most common
chronic rheumatologic disease in children and is one of
the most common chronic diseases of childhood.
The etiology is unknown, and the genetic component is
complex, making clear distinctions between the various
subtypes difficult.
A new nomenclature, juvenile idiopathic arthritis (JIA), is
being increasingly used to provide better definition of
subgroups.
51
45. Signs and symptoms
History findings in children with JIA may include the following:
Arthritis present for at least 6 weeks before diagnosis (mandatory
for diagnosis of JIA)
Either insidious or abrupt disease onset, often with morning
stiffness or gelling phenomenon and arthralgia during the day
Complaints of joint pain or abnormal joint use
History of school absences or limited ability to participate in
physical education classes
Spiking fevers occurring once or twice each day at about the same
time of day
Evanescent rash on the trunk and extremities
Psoriasis or more subtle dermatologic manifestations
46. Physical findings are important to provide criteria for
diagnosis and to detect abnormalities suggestive of
alternative etiologies, as well as to indicate disease
subtypes. Such findings include the following:
Arthritis: Defined either as intra-articular swelling on
examination or as limitation of joint motion in association
with pain, warmth, or erythema of the joint; physical
findings in JIA reflect the extent of joint involvement
Synovitis: Characterized by synovial proliferation and
increased joint volume; the joint is held in a position of
maximum comfort, and range of motion often is limited
only at the extremes
48. Arthritis must be present for 6 weeks before the
diagnosis of juvenile idiopathic arthritis (JIA) can be
made.
Disease onset is either insidious or abrupt, with
morning stiffness or gelling phenomenon (ie, stiffness
after long periods of sitting or inactivity) being a
frequent complaint and arthralgia occurring during the
day.
A morning limp that improves with time may be noted,
and a toddler may no longer stand in the crib in the
morning or after naps.
49. Complaints of joint pain may not be predominant in the
patients’ history, however; children often stop using joints
normally (eg, develop contractures of joints, decreased
wrist range, limp) rather than complain of pain. Up to a
quarter of children with oligoarticular JIA have no pain.
Individuals with JIA may have a history of school
absences, and their ability to participate in physical
education classes reflects the severity of the disease or
acute flares.
50. Physical Examination
JIA is a clinical diagnosis. A complete physical
examination is critical for the diagnosis.
Physical findings are important to provide criteria for
diagnosis and to detect abnormalities suggestive of
alternative etiologies.
The diagnosis of JIA is based on the physical finding of
arthritis in at least 1 joint that has persisted for at least 6
weeks, with other causes excluded, in an individual
younger than 16 years.
51. Systemic-onset JIA
A definite diagnosis of systemic-onset JIA must await
the development of arthritis. This may occur at onset of
the fever and rash or may lag by months or, rarely,
years.
52. Physical examination findings include
the following:
The child appears
systemically ill
Arthralgia is often present
The child may have
generalized myalgia
Evanescent, salmon-pink,
macular rash (often linear)
is found, predominantly on
the trunk and the
extremities; this rash, seen
in the image below, is
associated with fever spikes Systemic juvenile idiopathic arthritis
(JIA) rash
53. 62
Hepatosplenomegaly is often
present
Lymphadenopathy is
sometimes present,
especially the axillary lymph
nodes
Muscle tenderness to
palpation may be observed
Serositis, including pleural
and pericardial effusions,
may be present, as is noted
in the image below
Child with pericardial effusion
due to systemic onset juvenile
idiopathic arthritis
54. Chest pain or shortness of breath may be a sign of
pericarditis or pleuritis
Friction rub may occur in pericarditis but can be absent
with a large pericardial effusion
S3, basilar rales, and hepatomegaly suggestive of heart
failure may rarely be observed when myocarditis
occurs in individuals with systemic-onset JIA
55. Oligoarticular JIA
Characteristics of
oligoarticular JIA include
the following:
In individuals with
oligoarticular JIA, 4 or
fewer joints (and in many
cases, only 1 joint) are
affected
Large, weight-bearing
joints, such as the knees
and ankles, are typically
affected.
Eighteen-month-old girl with arthritis in
her right knee. Note the flexion
56. Children appear to be well, despite ambulating with a
limp
In cases of asymmetrical arthritis, chronic inflammation-
related hyperemia in a knee or ankle may lead to
overgrowth of that limb with subsequent leg-length
discrepancy
57. Muscle atrophy, often of
extensor muscles (eg, vastus
lateralis, quadriceps when
the knee is affected), may
occur
Flexion contractures in the
knees and, less commonly,
the wrists are found
Involvement of a few small
joints in the hands is atypical
and suggests eventual
development of polyarticular
JIA or psoriatic arthritis.
Dactylitis, or diffuse
tenosynovitis of a finger or
toe, also called a "sausage
digit," is more typical of
psoriatic arthritis or
enthesitis-related arthritis.
58. Children who are at lesser risk (ie, have polyarticular
disease and are ANA negative), are screened every 6
months for 7 years and then yearly. Children with
systemic JIA are at very low risk and are screened
yearly.
Acute anterior uveitis is one of the diagnostic criteria for
enthesitis-related arthritis. These children with are
screened initially and if symptomatic.
Older children with RF-positive polyarticular JIA should
probably be screened yearly. There are few data on
these children regarding their risk for uveitis.
59. Sequelae of chronic anterior uveitis. Note the posterior synechiae
(weblike attachments of the pupillary margin to the anterior lens
capsule) of the right eye secondary to chronic anterior uveitis. This
patient has a positive antinuclear antibodies (ANAs) and initially
had a pauciarticular course of her arthritis. She now has
polyarticular involvement but no active uveitis.
60. Polyarticular Juvenile Idiopathic
Arthritis
In polyarticular juvenile idiopathic arthritis, 5 or more joints
are affected in the first 6 months after disease onset,
weight-bearing joints are affected, rheumatoid nodules
may be seen in patients with RF-positive disease, and
symmetrical involvement of small joints in the hands is
often found, as seen in the images below.
61. Patient with active polyarticular arthritis. Note swelling (effusions) of
all proximal interphalangeal (PIP) joints in addition to boney
overgrowth. Also note lack of distal interphalangeal joint (DIP)
involvement. The patient has interosseus muscle wasting
(observed on the dorsum of the hands), and subluxation and ulnar
deviation of the wrists are present.
62. Decreased extension of the cervical spine is often asymptomatic. It is
indicative of arthritis of the cervical spine and can lead to subluxation,
typically of the C2 vertebra on C3. Fusion of the posterior elements of the
vertebra may occur.
Flexion and extension views of C-spine in child with poorly controlled
polyarticular juvenile idiopathic arthritis (JIA).
63. Treatment
The ultimate goals in managing rheumatoid arthritis are to
prevent or control joint damage, to prevent loss of function,
and to decrease pain. These goals are particularly important in
juvenile idiopathic arthritis (JIA), in which the rate of progression
and the onset of debility can be rapid. JIA is a chronic disease
characterized by periods of remission and flare. Treatment is
aimed at inducing remission with the least toxicity from
medications with hopes of inducing a permanent remission.
The success of therapy is monitored best with repeated
physical examinations and history. The number of joints
involved and the duration of morning stiffness should
demonstrate continued decrease, with elimination reflecting
success. Surgery may be indicated in patients who are
unresponsive to medical therapy.
64. A team-based approach to the treatment of JIA can be
helpful. Management may include 1 or all of the following
areas:
Pharmacologic therapy with nonsteroidal anti-
inflammatory drugs (NSAIDs), disease-modifying
antirheumatic drugs (DMARDs), biologic agents, or intra-
articular and oral corticosteroids
Psychosocial interventions
Measures to enhance school performance (eg, academic
counseling)
Improved nutrition
Physical therapy
Occupational therapy
66. Infestation
Infestation is the presence of animal
parasites on or in the body, is common in
tropical countries and less so in temperate
ones.
Infestations fall into two main groups:
1 those caused by arthropods; and
2 those caused by worms.
69. Transmission
directly by close personal contact, sexual
indirectly via fomites
factors
overcrowding
delayed treatment of primary cases
public awareness
70.
71. highly host-specific
an arthropod a member of the class
Arachnida, subclass Acari, order
Astigmata, and family Sarcoptidae.
Too small to be seen by the naked eye
Adult female measures ~ 0.4 - 0.3
mm, &
the smaller male 0.2 - O.15 mm
72. body is creamy white & is marked by transverse
corrugations,
ovoid
four-pairs of legs -
anterior two pairs end in elongated peduncles tipped
with small suckers,
In the female, the rear two pairs of legs end in long
bristles, whereas in the male bristles are present on
the third pair and peduncles with suckers on the
fourth.
crawl at a rate of 2.5 cm/min, burrow through the
stratum corneum at the rate of about 2 mm per
day(0.5 - 5 mm/day)
73. number - <20 & with crusted scabies
can be thousands to millions
live mites can survive for up to a week
in the environment, feeding on the
sloughed stratum corneum
cannot fly or jump
74. Mating takes place once, and the female is
fertile for the rest of her life (1 mo),
Copulation in a small burrow---------the
male, falls off the skin & perishes---------
Fertilized female enlarges the burrow
using proteolytic enzymes to dissolve the
stratum corneum of the epidermis -----
begins egg laying (3 eggs a day each)
Six-legged larvae emerge from the eggs
after 3-4 days
90% of the hatched mites die
75. Escape from the burrow by cutting through
its roof------then dig short burrows called
moulting pouches & transform into nymphs--
-----------After further moult into larger
nymphs , adult males and females develop(in
2-3 weeks)
76.
77. Clinical features
IP- 2-6 weeks
immediate symptoms –in re infection
Triad`s
Pruritic papular lesions,
Excoriations, and
Burrows
Site- The circle of Hebra ~ an imaginary circle
intersecting the main sites of involvement - axillae,
elbow flexures, wrists & hands, & crotch
78. Cont......
Pruritis
○ accentuate at night & exacerbated by a hot bath
or shower
Primary lesions of scabies
- burrows, papules, pustules, nodules,
occasionally urticarial papules and
plaques
interdigital webbing of the hands,
flexural aspect of the wrists, behind the
ears, axilla, waist, ankles, feet, buttocks
& belt area
penile & scrotal in men, areola, nipples
& genital area in women
80. In very young children, infants,
elderly and immunocompromised
hosts, a widespread eczematous
eruption primarily on the trunk is
common , scalp & face can also be
affected.
81. The burrow
pathognomonic sign and represent the
intraepidermal tunnel created by the
moving female mite.
a 1-10 mm tunnel
serpiginous, greyish-white
thread-like elevations
At the end of it a vesicle/pustule containing
the mite may be noted, especially in infants &
children
at entry, slight scale
82. In infants, commonly located on
the palms & soles : F
To identify burrows quickly:
apply a drop of India ink or
gentian violet to the infested area,
remove it with alcohol
Thin threadlike burrows retain
the ink
83. Erythematous Papules & Vesicles (filled with serous fluid)
rarely contain mites and most likely are due to a
hypersensitivity reaction
Papules= on the shaft of the penis & scrotum in men
& on nipples in women
Vesicles= on the palms & soles
84. Animal Scabies: Zoonotic scabies
affect humans who come in close contact with the
animal
incubation period is shorter, the symptoms are
transient
usually manifests with vesicles & papules with atypical
distribution
Burrows are usually absent
runs a self-limited course, require no treatment
Mites from animals are not a source of human
infestation, but they can produce bite reactions
Asymptomatic infestation
not uncommon
considered ‘carriers’
85.
86. Secondary scabies lesions
With rubbing- secondary infection, -
the host immune response against the
mites and their products.
Excoriations, Lichenification,
widespread eczema, honey-colored
crusting, postinflammatory
hyperpigmentation, erythroderma, and
frank pyoderma
87. Variants
Nodular scabies
in 7-10% of patients with active scabies
Pink, tan, brown, or dull red nodules
(2-20 mms)
May or may not itch
Persist on the scrotum, penis, and
vulva and In neonates
unable to scratch, pinkish-brown nodules may develop
usually sterile
Intralesional steroids, tar, or excision are methods of
treatment
88. Bullous scabies
Mimics BP both clinically &
histologically (contain many
eosinophils)
Vesicles and bullae-, particularly on
the palms & fingers
Immunofluorescent
89. In immunocompromised / debilitated
patients, including those with:
neurologic disorders, Down syndrome,
organ transplants, graft-versus-host
disease, adult T-cell leukemia, leprosy, or
AIDS and institutionalized populations
Risk factors for profound infestation
-an inability to mount an immune response,
perceive pruritis, and/or physically scratch
the skin
Crusted scabies
(Norwegian/hyperkeratotic scabies)
90. * marked thickening and crusting of
the skin.
* Hyperkeratotic, crusted/scaling
lesions teem with mites
* large areas with prominent scalp
lesions,
hands and arms are usual locations
* Swollen & crusted finger tips; &
dystrophic nails
91. Contd...
The rest of the skin usually appears diffusely
xerotic
highly contagious
Severe fissuring & scaling of the genitalia &
buttocks may be present
Oral agent should be used in conjunction with a
topical agent
93. Treatment
In infants with extensive involvement, several re
treatments a week apart occasionally be required
second application of topical medication.......
Treat simultaneously all household contacts (even with
no symptoms)
95. Pediculosis
Phthiraptera family
Order Anoplura-blood-sucking (***solenophages)
ectoparasites of mammals
Pediculus capitis, the head louse
Pediculus humanus, the clothing or body louse &
Pthitrus pubis, the pubic or crab louse
ingest blood, & produce skin lesions by mechanical
puncture( stylet, haustellum) & injecting toxic secretions
96. Pediculosis Capitis
Head lice
in school-aged children, 3-12yr, 10%of children : F
affect all levels of society & all ethnic groups
Prevalence= 6 to 12 million infestations/year
incidence is low among African Americans
spread by close physical contact
sharing of head gear, combs, brushes, & pillows
97. Etiology & Pathogenesis
is 1 to 2 mm long,
elongated,
greyish white flattened dorsoventrally, &
wingless
three pairs of sharp clow- grasp hairs and for feeding
feed approximately five times each day
5 - 10 eggs a day
can travel up to 23 cm/min
The larva, called a nymyh/instar, looks like a miniature
adult louse
1 - 2 days (4 days) away from the scalp (Nits up to 10 days)
30 days
*Head lice do not carry or transmit any human disease.
hatches in 8 to 10 days, and reaches maturity in
approximately 18 days. Nits are .8mm, with operculum
98.
99.
100. Clinical findings
Louse - occipital and retro auricular regions
<20 but in 5% >100
Itching or can be asymptomatic
a result of hypersensitivity reaction to the
saliva & faecal matter produced by the
louse during feeding
Sensitization - 3-8month
hemorrhagic crust
Excoriations, lymphadenopathy, &
conjunctivitis(redness &swelling) may be
observed
101. Diagnosis
Identification of live adult lice, immature nymphs,
and/or viable-appearing eggs
Live nits(egg cases) placed in close proximity to the
scalp(parietal & occipital)
Have proteinaceou sheath
cemented to the hair shaft with chitinous material
secreted by the female accessory glands
C0MPLICATIONS
Excoriation ----- Secondary bacterial infections
103. ETIOPATHOGENESIS
Body Iouse/P. humanus var humanus
lifespan -18 days
270 to 300 ova
2-4mm
3 day,with out meal
comes to the surface only for meal
104. CLINICAL FEATURES
linear excoriations primarily
Occasionally, a macula ceruleae (Iiterally, sky-
blue spot)
a blue to slightly slate-colored
macule.............bruise-like lesion (~1.5 cm) &
often with a central punctum 2nd to altered
blood pigments in clothing binds (waistband,
buttocks & thighs) & is asymptomatic to
slightly pruritic
105. Contd...
Diagnosis
examining the lining of
the clothing seams for
the presence of nits
By shaking out the
clothing over a sheet of
newsprint,
Nits that contain an
unborn louse fluoresce
white.
Nits that are empty
fluoresce gray.
106. COMPLICATIONS
Excoriation
secondary infection with S. aureus, S. pyogenes &
other bacteria (impetigo & furunculosis)
act as vectors for R.prowazekaii (epidemic typhus),
Bartonella quintana (trench fevers or endocarditis)
& Borrelia recurrentis (relapsing fever)
107. Pediculosis pubis (Pubic Lice)
EPIDEMIOLOGY
most often are a
sexually
transmitted disease
~ 30 % of patients
have another
concurrent STI
from one sexual
exposure with
an infested
partner is more
than 90%
contaminated
clothing,
towels, or
beddings
108. ETIOPATH0GENESIS
Pthiridae
crab - naming
second and third pairs of -to cling on to hair (pincer like claws)
light brown
0.8 to 1.2 mm in length
ambulate up to 10 cm/day
lifespan of 2 wks
25 ova
away from the human host for up to 36 hrs
dog
109. CLINICAL FEATURES
Pruritus
Maculae ceruleae (sky-blue spots, (tache bleu), on inner
thighs or sides of trunk
Bullous lesion
adult organisms on the body ( ~ 10 - 25 or more)
pubic hair, any hair bearing site can be affected,
eyelashes ((phthiriasis palpebrarum
○ in hirsute ~ short hairs of the thighs, trunk, &
perianal area
nits near the base of the hair
the duration of infestation can be approximated by
the distance of the nit from the skin surface
110.
111. The Skeletal System
The skeleton is the name given to the collection of
bones that holds our body up. It does three major
jobs.
A. It protects our vital organs such as the brain,
the heart, and the lungs.
B. It gives us the shape that we have
C. It allows us to move..
. When we were born our skeleton had around
350 bones. By the time we become an adult, we
will only have around 206 bones
Introduction
112. Bone comes in several shapes and sizes the structure
and composition of bone is the same in all. Bone is
composed of protein , minerals and cells.
The main part are:
shaft
neck
head
113. A tumor is a lump or mass of tissue that forms
when cells divide uncontrollably. A growing
tumor may replace healthy tissue with abnormal
tissue. It may weaken the bone, causing it to
break (fracture).
114. A bone tumor is an abnormal growth of cells within the
bone that may be noncancerous (benign) or cancerous
(malignant).
115. Malignant
Benign
Fatal without treatment
May recur after removal
Rarely fatal
Rarely recur after removal
Rapid growth
Slow growth
Distant metastases , not
localized
No metastases , localized
The difference between
benign and malignant
tumors
116. Enneking described the most widely used
staging system for (benign bone tumors )
The stages are denoted by the Arabic
numerals 1, 2, and 3, whereas malignant
bone tumors are classified by Roman
numerals (I, II, III).
Many benign bone tumors have the potential
to present at, and progress through, various
stages during their disease course.
Stage of benign tumors
117. . Stage 1-LATENT, it do not have any
characteristics of growth or progressive
change, may resolve spontaneously.
Stage 2-ACTIVE, lesion deform the host
bone but remain contained in bone, require
intralesional curettage.
Stage 3-AGGRESSIVE , tumor extend
beyond the bone, require complete work-up
and a removal with wide margins to avoid
possible local recurrence.
Stage of benign bone
tumors
118. The staging system for malignant tumor
adopted by the Musculoskeletal Tumor
Society, and originally developed by
( Enneking) is based on the histological
grade, the local extent(Tumors whether they
are intra-compartmental or extra-
compartmental)
and the presence or absence of metastasis
Stage of malignant bone
tumors
119. Stage IA is defined as G1 and Intra-
compartmental
Stage IB is G1 and extra-compartmental
Stage IIA is G2 and Intra-compartmental
Stage IIB is G2 and extra-compartmental
Stage III is G1 or G2, intra- or extra-
compartmental, and has evidence of metastasis
Stage of malignant bone
tumors
122. Is a tumor which have spread from other organs ,The
most common cancers that spread to the bone are
cancer of the:
1. Breast
2. Kidney
3. Lung
4. Prostate
5. Thyroid
These forms of cancer usually affect older people
metastatic tumors
123. 1. Age
2. Combinations of radiation and chemotherapy for
treating prior cancer
3. Certain kinds of anti-cancer drugs (alkylating
agents)
4. Family history of bone cancer
5. An overactive parathyroid gland
6. Multiple benign tumors
7. Osteomyelitis
8. Radiation
Risk factors
124. 1. Movement problems
2. Stiff bones
3. Bone lumps and masses
4. Bone tenderness
5. Anemia
6. Weight loss, Fatigue
7. Bone pain, may be worse at night
8. fevers and night sweats
9. Bone fracture, especially fracture from slight
injury (trauma)
10. Note: Some benign tumors have no symptoms
Clinical features
125. The cause of bone tumors is unknown. They
often arise in areas of rapid growth
Inherited genetic mutations
Radiation
Trauma
Causes
126. 1. Delayed wound healing
2. Nutritional deficiency
3. Infection
4. Hypercalcaemia
5. Muscle wasting, bone weakening
6. Pathological fracture
7. Temporary burn to the skin and fatigue from
radiation therapy
Complications
127. 8. Nausea, vomiting, mouth sores, hair loss, and lowered
resistance to infection from chemotherapy.
9. Infection of the surgical site and possible blood clotting
disturbances from surgery.
10. Pain
11. Spread of the cancer to other nearby tissues
(metastasis)
Complications
128. Blood test
Bone biopsy
Bone scan computed tomography (CT).
MRI ( magnetic resonance imaging )
X-ray of bone
CT scan
Diagnosis & Tests
129. Open Biopsy
Needle Biopsy
insert a needle into the tumor to remove
some tissue
small incision is made and the tissue is
removed
removal of a sample of bone tissue to test for
cancer cells.
Bone biopsy:
130. Systemic therapy
Local therapy 1.Chemotherapy
2. hormone therapy
3. Immunotherapy ex.
Interferon α
1.Radiation therapy
2. surgery
Nutritional therapy
• Provide foods high in protein,
vitamins and folic acid.
131. Hormone therapy
removal of the organs which produce hormones
which can promote the growth of certain types of
cancer (such as testosterone in males and
estrogen in females), or drug therapy to keep the
hormones from promoting cancer growth.
Chemotherapy
used to kill tumor cells when they have spread
into the blood stream
Systemic therapy
132. Radiation Therapy
Radiation therapy uses high-dose x-rays to kill
cancer cells and shrink tumors. may be given
either before or after surgery
Local therapy
133. Surgical Treatment
Amputation
Rotationplasty
Bone graft
Artificial bone
removes all or part of an arm or leg when the tumor is large and/or
nerves and blood vessels are involved.
is a form of amputation, in which the patient's foot is turned
upwards in a 180 degree turn and the upturned foot is used as a
knee.
affected bone is removed, bone from elsewhere from
the body is taken.
affected bone is removed, putting an artificial bone in.
Local therapy
134. Narcotics
Analgesics
Ex. Biphosphonates
are drugs that can be used to reduce bone pain and
slow down bone damage in people who have cancer
that has spread to their bones and increase bone
strength
Ex. Metastron also known as strontium-89 chloride is
an intravenous medication given to help with the pain
and can be given in three month intervals
Pain medications
135. Age: Bone tumor are more common in
children and young adults when bones grow
rapidly
The incidence of bone cancer is higher in
families with familial cancer syndromes. The
incidence of bone cancer in children is
approximately 5 cases per million children
each year , in united states
Epidemiology
137. Collection Of Subjective Data:
1. Bone pain in the area of the tumor, may be worse at night, pain is
generally described as dull and achy
2. pain may or may not get worse with activity
3. Fatigue, anxiety
Collection Of Objective Data:
1. Bone lumps and masses determining the location and size of tumor
,soft tissue swelling
2. Stiff bones
3. Weight loss
4. Bone fracture, especially fracture from slight injury (trauma)
5. fevers and night sweats
6. Movement problems
7. Anemia
Nursing
assessment
138. Acute or
chronic pain
related to
the
pathologic
process and
surgery
Control
of pain
Administer analgesics
as necessary. Make sure
the patient has received
his analgesic before
morning care or any
activity that may increase
pain
Regularly monitor the
patient’s degree of pain
and the effectiveness of
analgesics and other pain
relief measures, such as
positioning or guided
imagery
Experiences no
pain or
decreased pain
Nursing
evaluation
Nursing Implementation
Nursing
Planning
Nursing
Diagnosis
1
139. Nursing
evaluation
Nursing
Implementation
Nursing
Planning
Nursing
Diagnosis
Deficient
knowledge
related to the
disease
process and
therapeutic
regimen
Giving
knowledge
about the
disease
process and
treatment
regimen
Promoting
understanding of the
disease process and
treatment
regimen(Provide foods
high in protein, vitamins
and folic acid)
Don’t give I.M.
injections or take rectal
temperature
During radiation
therapy or
chemotherapy, take
measures to reduce
adverse reactions, such
as providing the patient
with plenty of fluids to
drink and saline
mouthwash for gargling
Described
disease process
and treatment
regimen
2
144. OBJECTIVES
1-Introduction of accidental prevention.
2-Developmental stages, common problems of each
stage and its prevention.
-Road Traffic Accidents(RTAs).
-Burns and Scalds.
-Electrocution.
-Drowning and Near-Drowning.
-Chocking, Suffocation and Strangulation.
-Poisoning.
-Cuts.
3-General safety precautions that need to be taken by
the parents or caregivers.
-Infants. –Toddlers
-Preschoolers.
-School Age Children.
-Adolescents
145. Introduction
Injury prevention
Injuries cause more deaths in children
between the ages of 1 and 4 years than
in any other childhood age-group except
adolescence.
Childhood accidents at home and
outside are common but preventable.
The age is the most important factor
that affects children to have accidents.
146. Developmental stages and Common
:
problems of each stage
Infant
Burns extremity fractures
choking head injuries
motor vehicle accident near drowning
toxic ingestions
Toddler
Burns extremity fracture
choking head injuries
motor vehicle accidents near drowning
toxic ingestions bicycle injuries
147. Preschooler
Burns extremity fractures
falls motor vehicle accidents
toxic ingestions bicycle injuries
School child
Extremity fractures
motor vehicle accidents
sports injuries
Adolescent
Extremity fractures
motor vehicle accidents
sports injuries
near drowning ( common among males)
148. The common accidents in children as per age and the
preventive measures to be taken in order to prevent
them as the following:
1-Road traffic accidents(RTAs)
RTAs are the most common type of accidents that leads to death on
children in our state. boys between the ages of 5 and 12 years are
mostly confronting this type of accidents in our place. Children of
this age are school going and will not able to estimate the speed of
vehicles or dangers of traffic while crossing roads. so children must
be taught the practical aspects of road safety through demonstration
classes.
150. 2-Burns and scalds
These are the second most common cause of death from accidents. Most of these deaths are
due to carelessness of parents or caretakers. Scalds from boiling water and hot drinks are
common among children especially in toddlers. The common victims of burns with kerosene
lamps are school age children, who will be studying near kerosene lamps.
Prevention
152. 4-Drowning and near-drowning
Prevention
Drowning and near-drowning also cause death in children, especially in
preschoolers and school age children. children may get drowned in
streams, rivers, lakes, swimming pool and also in pits where water is
stagnated. Infants and toddlers are also not away from the risk of
drowning. This is usually occur at home. They get drowned in bathtubs and
water-filled vessels.
153. 5-Choking, suffocation and strangulation
Children may choke on vomit, toy's parts or aspiration of food and
fluids. Children strangle themselves on curtains, cloth cradles,
beddings and even necklaces and neckties, some children try to
imitate TV and cinema scenes and get strangulated. Airway
obstruction from aspirated foreign bodies can be recovered using
Heimlich maneuver in older children.
Prevention
154. 6-Poisoning
Prevention
Many children are admitted to hospital because
they have been poisoned by eating or drinking or
even inhaling poisonous substances. Some of these
children die. To prevent these types of deaths,
adults need to be vigilant. Substances such as
medicines, petrol, household cleaning materials,
etc., need to be stored high up so that children
can't reach them.
155. 7-Cuts
Prevention
Cut injuries are also common among children. They
may use carelessly placed knives, razors and blades to
experiment. Sharp edges of furniture also can be
injuries to children.
156. General safety precautions that need to
be taken by the parents or caregivers
Infants Toddlers Preschoolers
Adolescents
