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This combusts more readily making the when tolerance is reduced lady era 100mg discount, or if other drugs or alcohol cocaine more potent buy generic lady era 100mg line. Social problems include loss of job buy lady era 100mg mastercard, deterioration in The street term ‘freebasing’ means smoking cocaine, ei- relationships and criminal activities to obtain money ther as the salt or base. Cocaine and crack can also be to buydrugs,includingstealing,prostitutionanddrug injected, although this is far less common. Incidence/prevalence Investigations 7% of 20–24 year olds have tried cocaine, mainly snort- These depend on the presentation of the individual. About 10–15% of those who try snorting cocaine vestigations may be needed for possible complications become abusers. Crack is linked with areas of social depending on the history and clinical diagnosis. Heroin intoxication is treated by ensuring airway pro- tection, and giving the opiate antagonist naloxone. Tolerance does seem to occur to some not cause euphoria, is used as a method of programmed extent. Baseformsofcocaine, Supportive therapy is needed to prevent the patient from including crack, have a more rapid onset but a much seeking increased doses (either of heroin, other drugs or shorter duration of action. In alcohol, its effects are increased by an active metabolite, some cases, patients stay on long-term methadone at which only forms in the presence of alcohol. Physical side effects include dilated pupils, dry mouth, 524 Chapter 15: Overdose, poisoning and addiction sweating, tachycardia and loss of appetite. Within half an 2 Agitation and hypertension often respond to di- hour of the last dose of a binge, there is a ‘crash’ when the azepam. Haloperidol and phenothiazines should be user feels intense cravings, depression and anxiety. Long-term users coronary vasoconstriction due to unopposed alpha may become persistently restless, with anorexia, weight effects). Smok- physical effects from withdrawal so sedatives or a re- ing can cause granulomas and pulmonary oedema. Other medical tension or myocardial ischaemia) and antidepressants complications include hypertension, myocardial in- may be indicated. Definition r Social: The most common reason for a cocaine ad- Amphetamines were originally widely used for medical dict to present for treatment of dependency is run- reasons such as appetite suppressants and for insom- ning out of money, as a cocaine or crack binge can nia, but are now recreationally used. Other prob- phetamine (and derivatives) is now limited to selected lems include loss of job and criminal activities such as cases of narcolepsy and attention deficit hyperactivity stealing, prostitution and drug dealing. There are several derivatives of amphetamine, such Investigations as methamphetamine, which can be smoked, and there- These depend on the presentation of the individual. Co- fore became popular for their increased speed of on- caine use can be tested for using a urine screen. Amphetamines can be taken gations may be needed for possible complications such orally, intranasally, smoked or injected. Management Cocaine intoxication: Initial management includes en- Incidence/prevalence suring a clear airway and ventilation if needed. Amphetamineandderivatives(includingecstasy)arethe 1 Seizures are treated with diazepam or lorazepam. Chapter 15: Alcohol and drugs of abuse 525 Pathophysiology 1 Seizures and agitation are treated with diazepam or Amphetamines are stimulant drugs with cardiovascular, lorazepam. Multi- 2 Hypertension should be treated with diazepam or ple doses, taken to maintain euphoria, can lead to intox- if this is ineffective, intravenous glyceryl trinitrate ication, and feelings of anxiety and paranoia. The excre- tion of amphetamine depends on urine pH – acid urine increases its clearance. Ecstasy abuse Definition Clinical features Ecstasy is a semi-synthetic derivative of amphetamine Physical effects of an amphetamine-intoxicated state in- with hallucinogenic properties. A history should be taken of re- usually comes in tablets or capsules, which may have centandpreviousrecreationaldruguse,includingmeth- logos or pictures on them. Occasionally it is and social history should be taken, as well as a medical found in a powder form that is smoked or snorted. Incidence/prevalence Complications Ecstasy use continues to rise, doubling in the last 5 Medical complications include seizures, coma, tach- years. Acute ecstasy, with rates approaching 30% in university stu- hepatic failure has been reported. There have been over 200 deaths from the drug in tions include paranoia, eating disorders, hallucinations 15 years. If physical side-effects highly variable, but in addition idiosyncratic responses are present, U&Es, liver function tests, creatine kinase appear to occur, both in naıve and chronic users. Clinical features r Effects begin within an hour and usually last 4–6 Management hours, but may persist for 48 hours with very high In more than mild toxicity, patients should have cardiac doses. Increasedthirstcanbemarked,suchthatex- 5 Metabolic acidosis should be corrected with sodium cessive water intake occurs, leading to hyponatraemia. Mood effects are 6 Narrow complex tachycardias are treated with intra- of euphoria, and ecstasy is unique in its ability to make venous β-blockers.

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Large gatherings like the urbanisation and to the distinctive epidemiological Olympic Games and the football World Cup now take pattern of transmittable diseases in cities lady era 100 mg lowest price. The Whenever possible buy lady era 100 mg low cost, local governments should epidemiological transition in cities and the changes in incorporate health concerns into urban policies 100mg lady era overnight delivery, such as the perception of risk by travellers visiting them oblige economic promotion and community development. The specialists in travel medicine to adjust their Healthy Cities programme is a trans-sectoral approach recommendations frequently. In Marikina, Philippines, the combination of riverside clean-up campaigns, Conclusion: opportunities for action improvements in waste-management services, health Urbanisation increasingly affects the epidemiological education, and resettlement programmes resulted in a characteristics of infectious diseases. This developed cities, better living conditions, improvement of collaborative initiative involved reallocation of health domestic hygiene, and targeted public-health interventions staff, health-promotion programmes in schools, and a started the decline of infectious illnesses. In parallel, pilot implementation of dry-sanitation toilets in informal chronic diseases have progressed because of changes in settlements. Features and determinants of urban health Search strategy and selection criteria status. From exposure to disease: the role of environmental terms (ie, “diarrhoea”, “intestinal diseases, parasitic”, factors in susceptibility to and development of tuberculosis. Migrant “slums”, and “infectious diseases”, and references from workers and schistosomiasis in the Gezira, Sudan. Articles were selected on the basis of urinary schistosomiasis in Dar es Salaam, Tanzania. Migration preparedness for worldwide outbreaks, and containment and urban schistosomiasis. Urban health should therefore be viewed 20 Reyburn H, Rowland M, Mohsen M, Khan B, Davies C. The as an international and worldwide issue, and appropriate prolonged epidemic of anthroponotic cutaneous leishmaniasis in resources should be allocated to reduce inequities. The burden of Acknowledgments diarrhoea, shigellosis, and cholera in North Jakarta, Indonesia: We thank Jean-Claude Bolay at Ecole Polytechnique Fédérale de Lausanne findings from 24 months surveillance. Intestinal helminthiases among rural and urban schoolchildren in south-western Nigeria. Leptospira interrogans among domestic rats from an urban setting highly endemic for leptospirosis in Brazil. Measuring the global burden of disease and epidemiological transitions: 2002–2030. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Marked differences health implications for children living in outlying urban settlements in the prevalence of chloroquine resistance between urban and in Salvador, Bahia State, Brazil. Household multidrug-resistant tuberculosis in urban and rural India and structure and urban services: neglected targets in the control implications for prevention. Risk factors for Mycobacterium tuberculosis in selected urban and rural areas in infection during a severe dengue outbreak in El Salvador in 2000. Why do poor people behave results of a household-based seroepidemiologic survey, December poorly? Periurban Trypanosoma Kampala, Uganda, and theoretical models for improving syndromic cruzi-infected Triatoma infestans, Arequipa, Peru. New York: Oxford disease among rural-to-urban migrants in China: implications for University Press, 2000. Household survey of urban and rural southwest Nigeria: its cultural, social and dengue infection in central Brazil: spatial point pattern attitudinal context. Impact of 72 Tornee S, Kaewkungwal J, Fungladda W, Silachamroon U, environment and social gradient on leptospira infection in urban Akarasewi P, Sunakorn P. Slum health: diseases of Southeast Asian J Trop Med Public Health 2005; neglected populations. The burden of disease in public health-related variables among women in Bangladesh: profile of residents of Nairobi’s slums: results from a demographic a cross-sectional study. Knowledge, attitudes and practices of women towards 75 Ambert C, Jassey K, Thomas L. Visceral leishmaniasis epidemic mortality millennium development goal in urban sub-Saharan in the State of Piauí, Brazil, 1980–1986. Rev Saude Publica 1990; Africa: the dynamics of population growth, immunization, and 24: 361–72 (in Portuguese). The present situation of human and canine visceral leishmaniasis in Belo Horizonte, regarding lymphatic filariasis in Cabo de Santo Agostinho, Minas Gerais State, Brasil, 1994–1997. Lancet leishmaniasis in the endemic area of Porteirinha Municipality, 1999; 353: 1541. Travelling waves in Diversity and species composition of sand flies (Diptera: the occurrence of dengue haemorrhagic fever in Thailand. Lutzomyia longipalpis in Clorinda, haemorrhagic fever, and its emergence in the Americas. Formosa province, an area of potential visceral leishmaniasis World Health Stat Q 1997; 50: 161–69. Trypanosoma cruzi, the etiologic agent of Chagas’ bodies in urban Lagos, southwestern Nigeria.

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