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Jama. Jun 26 2013;309(24):2535–2536. 24. O’donnell m, mente a, rangarajan s, et al. Urinary sodium and potassium excretion, mortality, and cardiovascular events. N engl j med. Aug 14 2014;371(7):612–623. 25. Sacks fm, svetkey lp, vollmer wm, et al. Effects on blood pressure of reduced dietary sodium and the dietary approaches to stop hypertension (dash) diet. Dash-sodium collaborative research group. N engl j med. 2001;344(1):3–10. 26. Izzo jl, jr, black hr. Hypertension primer.

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Calcium and vitamin d based on age and gender requirements t-score –1. 0 to –2. 5 and frax 10-year risk. Less than 3% hip less than 20% major osteoporotic • bone healthy lifestyle. Calcium and vitamin d based on age and gender requirements • medication therapy to prevent further bone loss can be considered if risk factors exist • reevaluate bmd in 2 or more years or as appropriate t-score less than –2. 5 or t-score –1. 0 to –2. 5 and frax 10-year risk. 3% or greater hip 20% or greater major osteoporotic • investigate for a secondary cause and treat as appropriateb • bone-healthy lifestyle. Calcium and vitamin d based on age and gender requirements • drug therapy. 1st line. 1a. Bisphosphonated 1b.

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Pancreatic exocrine and biliary function are also reduced in newborns, buy viagra online uae with about 50% less secretion of amylase and lipase than adults, reaching adult values as early as the end of the first year and as late as 5 years of age. Deficiency in pancreatic secretions and bile salts in newborns can decrease bioavailability of prodrug esters, such as erythromycin, which requires solubilization or chapter 3  |  pediatrics  23 volume of distribution table 3–2  maintenance fluid calculations by body weight patient body weight maintenance fluid requirement < 10 kg 11–20 kg > 20 kg 100 ml/kg/day 1000 ml + 50 ml/kg over 10 kg 1500 ml + 20 ml/kg over 20 kg intraluminal hydrolysis. 15 due to limited data on oral bioavailability of medications in infants and children for newer agents, some drug dosing recommendations may be extrapolated from adult safety and efficacy studies and case reports. Topical or percutaneous absorption in neonates and infants is increased due to a thinner stratum corneum, increased cutaneous perfusion, and greater body surface-to-weight ratio. Hence, application of topical medications, such as corticosteroids, should be limited to the smallest amount possible. Limiting exposure can help minimize serum concentrations of active drug as well as inactive, yet potentially harmful additives such as propylene glycol. Intramuscular absorption in premature and full-term infants can be erratic due to variable perfusion, poor muscle contraction, and decreased muscle mass compared with older patients. 19 intramuscular administration may be appropriate for some medications. However, use of this route of administration can be painful and is usually reserved when other routes are not accessible, for example, initial iv doses of ampicillin and gentamicin for neonatal sepsis. Intrapulmonary absorption and disposition is largely due to anatomical size of the lungs and drug delivery. The smaller airways of neonates and lower inspiratory volume can result in greater drug concentrations in the upper and central airways. Particle size, breathing pattern, and route (eg, oral vs nasal) can impact the amount of drug absorbed and should be considered when utilizing pulmonary drug delivery devices such as nebulizers or inhalers. 17 rectal absorption can also be erratic due to uncontrollable pulsatile contraction and risk of expulsion in younger patients (ie, infants and young children). 18 thus, it is not commonly recommended if other routes are available. This route is useful in cases of severe nausea and vomiting or seizure activity. For medications that undergo extensive first-pass metabolism, bioavailability increases as the blood supply bypasses the liver from the lower rectum directly to the inferior vena cava. Availability of rectal dosage forms varies and use of oral medications or other dosage forms rectally is based on limited studies and case reports. Patient encounter, part 1 ts is a 32-week ga premature baby boy weighing 2 kg, length 42 cm, born to a 21-year-old woman this morning. What is ts’s weight classification as a neonate?. Calculate ts’s corrected age for ts 8 months from today. How much maintenance fluid would you recommend for ts at birth?. In pediatric patients, apparent volume of distribution (vd) is normalized based on body weight and expressed as l/kg. Extracellular fluid and total body water per kilogram of body weight are increased in neonates and infants, resulting in higher vd for water-soluble drugs, such as aminoglycosides, and decreases with age. Therefore, neonates and infants often require higher doses by weight (mg/kg) than older children and adolescents to achieve the same therapeutic serum concentrations. 15,18 the use of extracorporeal membrane oxygenation (ecmo) can further effect vd of medications in patients due to the added volume from the circuit and potential fluid changes (eg, edema) while on the circuit. Thus, the use of additional, close clinical and, when available, therapeutic drug monitoring is recommended for those patients requiring ecmo. 19 neonates and infants have a lower normal range for serum albumin (2–4 g/dl, 20–40 g/l), reaching adult levels after 1 year of age. Highly protein bound drugs, such as sulfamethoxazole-trimethoprim, are not typically used in neonates due to theoretical concern for bilirubin displacement. This displacement may result in a complication known as kernicterus, from bilirubin encephalopathy. 20 although neonates have lower body adipose composition compared with older children and adults, their overall vd for many lipid-soluble drugs (eg, lorazepam) is similar to infants and adults. Some medications (eg, vancomycin, phenobarbital) may also reach higher concentrations in the central nervous system of neonates due to an immature blood-brain barrier. 18 metabolism hepatic drug metabolism is slower at birth in full-term infants compared with adolescents and adults, with further delay in premature neonates. Phase 1 reactions and enzymes, such as oxidation and alcohol dehydrogenase, are impaired in premature neonates and infants and do not fully develop until later childhood or adolescence. Accordingly, the use of products containing ethanol or propylene glycol can result in increased toxicities, including respiratory depression, hyperosmolarity, metabolic acidosis, and seizures, thus should be avoided in neonates and infants. Age at which cytochrome p450 isoenzymes (eg, cyp3a4, cyp2c19) activity reaches adult values varies, depending on the isoenzyme, with delayed development in premature infants.

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Louis ed, et al. Diagnostic guidelines in central nervous system whipple’s disease. Ann neurol. 1996;40(4):561-568. 38.