Microsoft word - suffer little children
Students tend to be more reckless and less affluent than their advisors. Perhaps because of this, the traditional approach of Health Services to students intending to travel has been to immunise generously and hope for the best. As students travel in ever greater numbers perhaps it is time to make a greater effort to highlight the real risks run by young travellers.
Risks and their prevention
Student travellers should be under no illusions that most parts of the world are more dangerous than the UK both from the point of view of road accidents and violence against the person. Possibly the most practical way of reducing these risks is to urge students very strongly to avoid any travel at night and to do what they can to ensure that drivers are sober and vehicles appear to be reasonably roadworthy.
2. Safer sex.
Applies not only to places with a greatly increased prevalence of HIV such as most of Africa and countries like Thailand but to southern Europe also where the prevalence is still substantially higher than in the UK.
3. Prudent eating and drinking.
With the general advice about peeling and cooking of food but consideration given to the use of single doses of eg ciprofloxacin for reasonably severe travellers diarrhoea especially when it is important that the student maintain peak physical fitness.
4. Vector borne diseases:
Bite avoidance using insect repellents and nets to protect against infections such as dengue and Japanese encephalitis as well as malaria.
In addition travellers to malarious areas must be informed that the risk of Falciparam malaria persists for three months after their return and they should seek a blood film during this time if they develop flu like symptoms with fever while the choice of antimalarials for students is going to be very much influenced by their cost as well as their efficacy as well by the real risk of infection which is massively greater for students going to Africa compared with any other destination. The cost of antimalarials for four weeks in an endemic zone based on BNF prices in March, 2001 are as follows:
Vaccine choice should be dictated by the evident risk to students, hepatitis A being most generally required by students travelling to insanitary parts of the world, the risk being five times as high in back packers as those staying in hotels in the same countries. Rabies and Japanese encephalitis vaccines both have a role in travellers going to endemic areas, particularly those going for longer periods and, in the case of Japanese encephalitis, in those travelling during the monsoon period and soon afterwards (July, August and September in South East Asia).
Students in the Himalayas, East Africa and South America may be tempted to climb technically easy peaks such as Kilamanjaro. They must be warned that physical fitness offers no protection against altitude sickness and that whereas diamox 250mg bd for the firs three days at 12,000 feet or above may protect them against the benign manifestations of acute mountain sickness such as headaches and insomnia, only gradual acclimatisation to altitude is proof against more severe problems such as pulmonary and cerebral oedema. Should breathless or confusion develop then descent is essential.
The relative frequency of infection in returned travellers hospitalised in Birmingham is as follows:
We currently manage Falciparum malaria with a three drug regimen of quinine, fansidar and doxycycline and it is therefore difficult to advise a reliable simple treatment that can be used for self medication abroad. Perhaps fansidar three tablets stat remains the best solution as students will certainly not have used this for prophylaxis but they must be urged that it is at best only a stop gap and they should seek local medical advice.
Diarrhoea in returned travellers
Diarrhoea which starts after return or which persists if often caused by giardiasis which is hard to prove from stool examination and my policy under these circumstances is to treat with tinidazole 2g repeated after one week and only to
investigate further if there is no response. Small bowel biopsies are nowadays easily taken at endoscopy and are probably the most useful next step.
It is important to remember that the important causes of fever in travellers will not be identified by routine laboratory tests eg malarial parasites will only be identified by a technician specifically looking for them and primary HIV infection, an increasingly important condition to identify given the advantages of early HIV treatment, will only be identified if people whose behaviour has put them at risk of HIV are tested specifically once glandular fever itself has been excluded. Antibodies to HIV may not develop until two weeks after the presentation of such an illness. Eosinophilia indicates an invasive helminthic infection and people who have fever and eosinophilia after swimming in lakes in Africa should be tested for schistosoma antibodies. A good history is vital before investigations can be undertaken.
Citocromo P450 e interazioni tra farmaci Gabriella Facciolà, Maria Gabriella ScordoIstituto di Farmacologia - Università degli Studi di Messina 1. Introduzione 2. Citocromo P450 3. Polimorfismo genetico 4. Interazioni tra farmaci 5. Conclusioni 6. Esempi di polimorfismo genetico 7. Esempi di interazioni tra farmaci 8. Citocromo P450 2D6 (CYP2D6) 9. Citocromo P450 3A4 (CYP3A4) 10. Citocrom
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