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Acuteangle closure glaucoma before surgery: 1 drop (2%) every 10 min for 30 to 60 min cheap aleve 500mg overnight delivery, then 1 drop every 1 to 3 h untl intra-ocular pressure subsides purchase aleve 250mg visa. Contraindicatons Acute irits, acute uveits, anterior uveits, some forms of secondary glaucoma; acute infammaton of anterior segment; not advisable afer angle-closure surgery (risk of posterior synechiae). Precautons Retnal disease, conjunctval or corneal damage; monitor intra-ocular pressure in chronic open-angle glaucoma and in long-term treatment; cardiac disease, hypertension; asthma; peptc ulceraton; urinary-tract obstructon; Parkinson’s disease; stop treatment if symptoms of systemic toxicity develop; ulcer; hyperthyroidism; seizures. Do not carry out skilled tasks, for example operatng machinery or driving untl vision is clear, pregnancy (Appendix 7c). Adverse Efects Eye pain, blurred vision, ciliary spasm, lacrimaton, myopia, browache; conjunctval vascular congeston, superfcial keratts, vitreous haemorrhage and increased pupillary block; lens opacites have occurred following prolonged use; rarely, systemic efects including hypertension, tachycardia; bronchial spasm, pulmonary oedema; salivaton; sweatng; nausea, vomitng, diarrhoea; fushing, rhinits, chills, middle ear disturbances. Contraindicatons Uncontrolled heart failure, bradycardia, heart block; asthma, obstructve airways disease; hypersensitvity. Precautons Older people (risk of keratts); if used in angle-closure glaucoma, use with a miotc, and not alone; interactons (Appendix 6c); pregnancy (Appendix 7c). Adverse Efects Stnging, burning, pain, itching, erythema, transient dryness, allergic blepharits, transient conjunctvits, keratts, decreased corneal sensitvity, diplopia, ptosis; systemic efects; partcularly on the pulmonary, cardiovascular and central nervous systems, may follow absorpton; blurred vision; headache. However, in some cases, for example, in gonococcal conjunctvits, both topical and systemic ant-infectve treatment may be neces- sary. Blepharits and conjunctvits are ofen caused by staphy- lococcus, while keratts and endophthalmits may be bacte- rial, viral or fungal. Although most cases of acute bacterial conjunctvits may resolve spontaneously, ant-infec- tve treatment shortens the infectous process and prevents complicatons. Acute infectve conjunctvits is treated with antbacterial eye drops by day and eye ointment applied at night. Gentamicin is a broad-spectrum bactericidal aminoglycoside antbiotc with partcular actvity against Pseudomonas aeru- ginosa, Neisseria gonorrhoea and other bacteria that may be implicated in blepharits or conjunctvits. Its antbacterial actvity is atributed to precipitaton of bacterial proteins by silver ions. It is available in 1% ophthalmic solutons and is used for prophylaxis of gonococcal ophthalmia neonatorum. Tetracycline is a broad spectrum antbiotc with actvity against many Gram-positve and Gram-negatve bacteria including N. Ophthalmic tetracycline is used in blepharits, conjunctvits, and keratts produced by susceptble bacteria. Tetracycline is also used in the treatment of trachoma caused by Chlamydia trachomats and in the prophylaxis of neonatal conjunctvits (ophthalmia neonatorum) caused by N. Precautons Maintain adequate hydraton (especially with infusion or high doses); monitor neutrophil count at least twice weekly in neonates; renal impairment (Appendix 7d); lactaton (Appendix 7b); pregnancy (Appendix 7c); not to be applied on mucous membrane. Adverse Efects Nausea, vomitng, abdominal pain, diarrhoea, headache, fatgue, rash, urtcaria, pruritus, photosensitvity; very rarely, hepatts, jaundice; dyspnoea; neurological reactons (including dizziness, confusion, hallucinatons, convulsions and drowsiness); acute renal failure; anaemia, thrombocytopenia and leucopenia; on intravenous infusion; severe local infammaton (sometmes leading to ulceraton), and very rarely, agitaton, tremors; psychosis and fever; increase in blood urea and creatnine, encephalopathy; seizures; anorexia, tremors. Contraindicatons Pregnancy (Appendix 7c), lactaton (Appendix 7b), porphyria; hypersensitvity. Precautons Avoid repeated courses and prolonged treatment; reduce doses in hepatc impair- ment (Appendix 7a); renal impairment; blood counts required before and peri- odically during treatment; monitor plasma- chloramphenicol concentraton in neonates; interactons: (Appendix 6c). Adverse Efects Blood disorders including reversible and irreversible aplastc anaemia (with reports of resultng leukaemia); peripheral neurits, optc neurits; headache; depression; urtcar- ia, erythema multforme; nausea, vomitng, diarrhoea; stomatts, glossits, dry mouth; nocturnal haemoglobinuria; grey syndrome (abdominal distension, pallid cyanosis, circu- latory collapse) may follow excessive doses in neonates with immature hepatc metabolism. Dose Adult and child above 12 years- Instll 2 to 3 drops in afected eye 3 to 4 tmes daily to start with thereafer reduce slowly as infecton subsides. Exposure to excessive sunlight should be avoided (discontnue if photosensitvity occurs). Avoid excessive alkalinity of urine and ensure adequate fuid intake (risk of crystalluria); interactons (Appendix 6c); paediatric use. Adverse Efects Nausea, vomitng, dyspepsia, abdominal pain, diarrhoea (rarely, antbiotc-associated colits); headache; dizziness; sleep disorders; rash (rarely, Stevens-Johnson syndrome and toxic epidermal necrolysis) and pruritus. Less frequent side-efects include anorexia, increase in blood urea and creatnine; drowsiness,restlessness,asthenia,depression, confusion, hallucinatons, convulsions, tremor, paraesthesia, hypoaesthesia; photosensitvity, hypersensitvity reactons including fever, urtcaria, angioedema, arthralgia, myalgia, and anaphylaxis; blood disorders (including eosinophilia, leucopenia, thrombocytopenia); disturbances in vision, taste, hearing and smell. Other side-efects that have been reported include haemolytc anaemia, renal failure, intersttal nephrits, and hepatc dysfuncton (including hepatts and cholestatc jaundice). The drug should be discontnued if psychiatric, neurological or hypersensitvity reactons (including severe rash) occur. Ophthalmic soluton:local burning, discomfort, corneal ulcers, lid oedema, corneal infltraton. Ointment: discomfort, keratopathy, blurred vision, corneal staining, epitheliopathy, photophobia. Dose Instllaton into the eye Adult- Mild to moderate infectons: 1 drop every 2 h, reducing frequency as infecton is controlled, then contnue for 48 h afer healing is complete. Precautons Prolonged use may lead to skin sensitzaton and emergence of resistant organisms including fungi; discontnue if purulent discharge, infammaton or exacerbaton of pain; ophthalmic ointment may retard corneal healing, renal impairment (Appendix 7d), interactons (Appendix 6c), pregnancy (Appendix 7c). Adverse Efects Burning; stnging; itching; dermatts; conjuctval epithelial defects;conjuctval hyperemia; thrombocytopenic purpurea; hallucinaton. Dose Adult and child-Fungal infecton of eye: instll 2 to 3 drops 3 to 4 tmes a day in infected eye or as required. Precautons Contact with eyes and mucous membranes should be avoided, pregnancy (Appendix 7c). Adverse Efects Occasional local irritaton and hypersensitvity reactons include mild burning sensaton, erythema; pruritus and itching. Oxytetracycline Pregnancy Category-D Schedule H Indicatons Infectons caused by susceptble pathogens, uncomplicated gonorrhoea, external bacterial infectons of the eye, acne vulgaris. Dose Oral Infectons caused by susceptble pathogens: Adult-250-500 mg 4 tmes daily. Therapy should be contnued for at least 24–48 hours afer symptoms and fever have subsided. Ophthalmic External bacterial infectons of the eye: Adult- Apply the ointment 2-3 tmes daily. Contraindicatons Hypersensitvity to tetracyclines, children below 8 years, renal impairment, pregnancy (Appendix 7c), lactaton. Precautons Hepatc impairment, myasthenia gravis, porphyria, elderly, interactons (Appendix 6b, 6c). Adverse Efects Corneal plaques, erythema multforme, blurred vision, stnging on applicaton. Dose Applicaton to the eye Adult- Superfcial bacterial infecton: 1 applicaton of ointment, 3 to 4 tmes daily.

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If suppressive doses are given for prolonged periods order aleve 500 mg mastercard, the adrenal cortex may undergo atrophy and this leads to a defciency on sudden withdrawal or dosage reducton or situatons such as stress or trauma where cort- costeroid requirements are increased order 500mg aleve amex. Afer high dosage or prolonged therapy, withdrawal should be gradual, the rate depending on various factors including patent response, cortcosteroid dose, duraton of treatment and disease state. The suppressive acton of a cortcosteroid on cortsol secre- ton is least when given in the morning. Cortcosteroids should normally be given in a single morning dose to atempt to mini- mize pituitary-adrenal suppression. Because the therapeutc efects of cortcosteroids are of longer duraton than the metabolic efects, intermitent therapy may allow the body’s normal metabolic rhythm and the therapeutc efects to be maintained. Alternate day dosing is, however, suitable only in certain disease states and with cortcosteroids with small mineralocortcoid efects and a relatvely short duraton of acton. Hydrocortsone is used in adrenal replacement therapy and on a short-term basis by intravenous injecton for the emer- gency management of some conditons. Its mineralocortcoid actvity is too high for it to be used on a long-term basis for disease suppression. The mineralocortcoid actvity of fudro- cortsone is also high and its ant-infammatory actvity is of no clinical relevance. It is the actve metabolite of prednisone, conversion of which is vari- able and prednisone should not be used interchangeably with prednisolone. Dexamethasone has very high glucocortcoid actvity in conjuncton with insignifcant mineralocortcoid actvity making it partcularly suitable for high-dose therapy in conditons where water retenton would be a disadvantage such as cerebral oedema. It also has a long duraton of acton and this, together with its lack of mineralocortcoid actvity makes it partcularly suitable for conditons requiring suppres- sion of cortcotrophin secreton such as congenital adrenal hyperplasia. Adverse Efects of Cortcosteroids: Overdosage or prolonged use may exaggerate some of the normal physiological actons of cortcosteroids leading to mineralocortcoid and glucocortcoid adverse efects. Mineralocortcoid adverse efects include hypertension, sodium and water retenton and potassium loss. These efects are most marked with fudrocortsone but are signifcant with hydrocortsone, occur slightly with prednisolone and are negligible with dexamethasone. Glucocortcoid adverse efects include diabetes mellitus and osteoporosis which is of partcular importance in the elderly since it may result in osteoporotc fractures of the hip or vertebrae. Mental distur- bances can occur, including serious paranoid state or depres- sion with risk of suicide, partcularly in patents with a history of mental disorders; euphoria is also common. High doses may cause Cushing syndrome (typical moon face, striae and acne), which is usually reversible on withdrawal of treatment, but this should always be tapered gradually to avoid symp- toms of acute adrenal insufciency (see also Withdrawal). In children, cortcosteroids may result in suppression of growth and cortcosteroids administered during pregnancy can afect adrenal development in the fetus. Any adrenal suppression in the neonate following prenatal exposure usually resolves spontaneously afer birth and is rarely, clinically important. Healing of wounds may be impaired and infectons and thin- ning of the skin may occur; spread of infectons may result from modifcaton of tssue reactons. Abrupt withdrawal afer a prolonged period may lead to acute adrenal insufciency, hypotension or death (see Withdrawal of Systemic Cort- costeroids, below). Withdrawal may also be associated with fever, myalgia, arthralgia, rhinits, conjunctvits, painful itchy skin nodules and weight loss. Cortcosteroid Cover During Stress: To compensate for a diminished adrenocortcal response caused by prolonged cortcosteroid treatment, any signifcant intercurrent illness, trauma, or surgery requires a temporary increase in cortcosteroid dose, or if already stopped, a tempo- rary re-introducton of cortcosteroid treatment. Anaesthetsts must therefore know whether a patent is taking or has been taking a cortcosteroid, to avoid a precipitous fall in blood pres- sure during anaesthesia or in the immediate postoperatve period. A suitable regimen for cortcosteroid replacement, in patents who have taken more than 10 mg prednisolone daily (or equivalent) within 3 months of surgery, is: • Minor surgery under general anaesthesia-usual oral cortcosteroid dose on the morning of surgery or hydrocortsone 25-50 mg intravenously at inducton; the usual oral cortcosteroid dose is recommenced afer surgery. Infectons: Prolonged courses of cortcosteroids increase susceptbility to infectons and increase their severity; clinical presentaton of infectons may also be atypical. Serious infectons, for example septcaemia and tuberculosis, may reach an advanced stage before being recognised, and amoebiasis or strongyloidiasis may be actvated or exacerbated (exclude before initatng a cortcosteroid in those at risk or with suggestve symptoms). Chickenpox Unless they have had chickenpox, patents receiving oral or parenteral cortcosteroids for purposes other than replace- ment should be regarded as being at risk of severe chickenpox on exposure. Passive immunizaton with varicella-zoster immunoglobulin is needed for exposed non-immune patents receiving systemic cortcosteroids or for those who have used them within the previous 3 months; varicella-zoster immunoglobulin should preferably be given within 3 days of exposure and no later than 10 days. Topical, inhaled or rectal cortcosteroids are less likely to be associated with an increased risk of severe chickenpox. Measles Patents taking cortcosteroids should be advised to take partcular care to avoid exposure to measles and to seek immediate medical advice if exposure occurs. In life-threatening diseases, high doses may be needed because the complicatons of therapy are likely to be less serious than the disease. In long-term therapy in rela- tvely benign chronic conditons such as rheumatoid arthrits, adverse efects ofen outweigh the advantages. In order to minimize the adverse efects, the maintenance dose should be kept as low as possible and if possible, single morning doses or alternate day therapy should be used. Glucocortcoids can improve the prognosis of serious conditons such as systemic lupus erythematosus, temporal arterits and polyarterits nodosa; in such disorders the efects of the disease process may be suppressed and symptoms relieved but the underlying conditon is not cured. In emergency situatons, hydrocortsone may be given intrave- nously; in the treatment of asthma, inhalaton therapy with beclomethasone may be used (chapter 20. Whenever possible, local treatment with creams, intra-artcular injec- tons, inhalatons, eye-drops or enemas should be used in preference to systemic therapy. Patents should be advised not to stop taking glucocortcoids abruptly unless permited by their doctor. Gradual withdrawal should be considered in those whose disease is unlikely to relapse and who have: • recently received repeated courses (partcularly if taken for longer than 3 weeks) • taken a short course within 1 year of stopping long- term therapy • other possible causes of adrenal suppression • received more than 40 mg daily prednisolone (or equivalent) • been given repeat doses in the evening • received more than 3 weeks’ treatment Abrupt withdrawal may be considered in those whose disease is unlikely to relapse and who have received treatment for 3 weeks or less and who are not included in the patent groups described above. During cortcosteroid withdrawal the dose may be reduced rapidly down to the physiological dosage (equivalent to 7. Assess- ment of the disease may be needed during withdrawal to ensure that relapse does not occur. Intramuscular injecton or slow intravenous injecton or intravenous infusion Adult- Initally 0. Contraindicatons See notes above; systemic infecton (unless life-threatening or specifc antmicrobial therapy given); avoid live virus vaccines in those receiving immunosuppressive doses (serum antbody response diminished); diabetes, hypertension, psychosis, osteoporosis, gastric ulceraton. Precautons Adrenal suppression during prolonged treatment which persists for years afer stopping treatment (see notes above); ensure patents understand importance of compliance with dosage and have guidance on precautons to reduce risks; monitor weight, blood pressure, fuid and electrolyte balance and blood glucose levels throughout prolonged treatment; infectons (greater susceptbility, symptoms may be masked untl advanced stage); clinical presentaton may be atypical; risk of chickenpox and measles increased (see notes above); quiescent tuberculosis- chemoprophylactc therapy during prolonged cortcosteroid treatment; elderly; children and adolescents (growth retardaton possibly irreversible); hypertension, recent myocardial infarcton (rupture reported), congestve heart failure, liver failure, renal impairment, diabetes mellitus including family history, osteoporosis (may be manifested as back pain, postmenopausal women at special risk), glaucoma including family history, epilepsy, psoriasis, peptc ulcer, hypothyroidism, history of steroid myopathy; lactaton (Appendix 7b); interactons (Appendix 6c); pregnancy (Appendix 7c). Dose Oral Adult-20 to 30 mg daily in divided doses (usually 20 mg in the morning and 10 mg in early evening). Slow intravenous injecton or intravenous infusion Adult- Acute adrenocortcal insufciency: 100 to 500 mg, 3 to 4 tmes in 24 h or as required.

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Mixed dairy product specified in paragraph (b) of this sec- chocolates are the foods that conform tion are used; and to the standard of identity buy aleve 500mg with amex, and are (3) The requirement in §163 buy aleve 500 mg free shipping. The fats, oils, and stearins (iii) Any dairy ingredients specified may be hydrogenated; in §163. The name of the referred to in paragraph (a)(1) of this food is "sweet cocoa and vegetable fat section, exclusive of any added sweet- coating". Alternatively, the common ener or other dairy-derived ingredient or usual name of the vegetable derived that is added beyond that amount that fat ingredient may be used in the name is normally present in the specified of the food, e. The name of the conforms to the definition and stand- food is "chocolate", or "chocolate ard of identity, and is subject to the re- coating", preceded by the designation quirements for label declaration of in- of the type of milk ingredients used as gredients for sweet chocolate in prescribed in paragraph (a) of this sec- §163. Sweet cocoa and vege- cluding only those dairy ingredients re- table fat coating is the food that con- ferred to in §163. The lll oil coating", the blank being fats, oils, and stearins may be hydro- filled in with the common or usual genated; name of the specific vegetable fat used. The name of the Subpart A [Reserved] food is "sweet chocolate and vegetable Subpart B—Requirements for Specific fat coating". Alternatively, the com- Standardized Tree Nut and Peanut mon or usual name of the vegetable de- Products rived fat ingredient may be used in the name of the food, e. The ingredient when used shall be present oils, fats, and stearins may be hydro- in a quantity not less than 2 percent genated; and not more than 80 percent by weight (2) Safe and suitable dairy-derived in- of the finished food. For purposes of gredients; and this section, each kind of tree nut and (3) Safe and suitable bulking agents, peanut is an optional ingredient that formulation aids, humectants, and may be prepared by any suitable meth- texturizers. The finished food may food is "milk chocolate and vegetable contain one or more of the optional fat coating" or "skim milk chocolate nonnut ingredients provided for in and vegetable fat coating", as appro- paragraph (c) of this section. I (4–1–10 Edition) (b) The optional shelled nut ingredi- than 16 ounces, enough containers to ents referred to in paragraph (a) of this provide a total quantity of at least 24 section are: pounds of nuts. Calculate the av- combination of two or more such vari- erage percentage of each nut ingredient eties. If the average percent found (c) The optional nonnut ingredients for each nut ingredient present is 2 per- referred to in paragraph (a) of this sec- cent or more and none of the individual tion consist of suitable substances that nut ingredients exceeds 80 percent by are not food additives as defined in sec- weight of the finished food, the lot will tion 201(s) of the Federal Food, Drug, be deemed to be in compliance with the and Cosmetic Act; or if they are food percentage requirements of paragraph additives as so defined, they are used in (a) of this section. If the average per- conformity with regulations estab- cent found for a single nut ingredient lished pursuant to section 409 of the exceeds 50 percent by weight of the fin- act. Nonnut ingredients that perform a ished food and the average percent useful function are regarded as suit- found is within the range indicated by able, except that color additives are the number declared on the label in ac- not suitable ingredients of the food. If the percentage of a single tree with the labeling requirements of this nut ingredient or the total peanut con- paragraph. Each of the in- ceeds 50 percent but not 60 percent, the gredients used in the food shall be de- statement "contains up to 60% lll" clared on the label as required by the or "contains 60% lll" or "60% applicable sections of parts 101 and 130 lll" shall immediately follow the of this chapter, except that: name "mixed nuts" and shall appear on (1) If the Spanish variety of peanuts the same background, be of the same is used, it shall be declared as "Spanish color or, in the case of multicolors, in peanuts". Other varieties of peanuts the color showing distinct contrast shall be declared as "peanuts", or al- with the background, and be in letters ternatively "lll peanuts", the blank not less than one-half the height of the being filled in with the varietal name largest letter in the words "mixed of the peanuts used. The blank is to be filled in with (2) If the peanut ingredient or ingre- the appropriate name of the predomi- dients as provided for in paragraph nant nut ingredient; for example, (b)(2) of this section are unblanched, "contains up to 60% pecans" or "con- the label shall show that fact by such tains up to 60% Spanish peanuts". The statement as "Peanuts unblanched", numbers "70" or "80" shall be sub- "Peanuts skins on", or words of simi- stituted for the number "60" when the lar import, unless the vignette clearly percentage of the predominant nut in- depicts peanuts with skins on. Com- fied in paragraph (e) of this section pliance with the requirements for per- showing the ingredients present shall centage of nut ingredients of this sec- be listed on the principal display panel tion and the fill of container require- or panels or any appropriate informa- ments of §164. The entire resenting the average height of the ingredient statement shall appear on product, read the volume of the nuts, at least one panel of the label. Raise label bears any pictorial representa- the cylinder 2 inches and allow it a free tion of the mixture of nuts, it shall de- vertical drop onto a level, firm, but re- pict the relative proportions of the nut silient surface (do not tamp) for a total ingredients of the food. If the label of 5 times and observe the volume as bears a pictorial representation of only above. Repeat in successive five-drop one of each nut ingredient present, the increments until the nuts have so set- nuts shall be depicted in the order of tled that the volume decreases less decreasing predominance by weight. A than 2 percent in the last five-drop in- factual statement that the food does crement. Read the last volume in the not contain a particular nut ingredient manner described above and record as or ingredients may be shown on the the settled volume. The arithmetical label if the statement is not misleading average of the loose volume and the and does not result in an insufficiency settled volume equals the average vol- of label space for the proper declara- ume of nuts. For such (i) For the shelled nuts in each con- containers used to enclose vacuum tainer, determine the loose volume, the packs and containing 4 ounces or less settled volume, and the average vol- of the product, consider the height to ume in cubic centimeters. For the pur- be the inside height minus three- poses of this subparagraph, consider eighths inch. For proximately 17⁄8 inches; but if the loose metal cans with indented ends (that is, volume is 500 milliliters or more, use a metal cans with ends attached by dou- 1,000–milliliter cylinder with an inside ble seams), consider the height to be diameter of approximately 21⁄4 inches. The in section 201(s) of the Federal Food, result shall be considered to be the per- Drug, and Cosmetic Act (the act), or if cent fill of the container. Seasoning and stabi- label shall bear the general statement lizing ingredients that perform a useful of substandard fill specified in function are regarded as suitable, ex- §130. Oil (a) Peanut butter is the food prepared products used as optional stabilizing by grinding one of the shelled and roasted peanut ingredients provided for ingredients shall be hydrogenated veg- by paragraph (b) of this section, to etable oils. For the purposes of this which may be added safe and suitable section, hydrogenated vegetable oil seasoning and stabilizing ingredients shall be considered to include partially provided for by paragraph (c) of this hydrogenated vegetable oil. To the ground pea- name shall show that fact by some nuts, cut or chopped, shelled, and such statement as "prepared from roasted peanuts may be added. Fat—Official First Action, Direct Method," in paragraph (a), which is in- (e) Label declaration. It does not include Standardized Beverages those food ingredients that are de- 165. On request, plants shall dem- tainer code or marking, a day’s produc- onstrate to appropriate regulatory offi- tion. I (4–1–10 Edition) of water by its constant level and rel- location of the spring shall be identi- ative proportions of minerals and trace fied. Spring water collected with the elements at the point of emergence use of an external force shall be from from the source, due account being the same underground stratum as the taken of the cycles of natural fluctua- spring, as shown by a measurable hy- tions. If spring water is 1995, which is incorporated by reference collected with the use of an external in accordance with 5 U. For fined terms describing the water in this information on the availability of this paragraph (e. There shall be a natural content", respectively, shall appear on force causing the water to flow to the the principal display panel following surface through a natural orifice. This to two significant figures after addi- statement shall immediately and con- tion.

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