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Canadian guidelines on sexually transmitted infections, 2006 edition

Canadian Guidelines on Sexually Transmitted
Infections, 2006 Edition
This article highlights the changes that have occurred during the revision process of the 1998 Canadian STD Guidelines. The complete Canadian Guidelines on Sexually
Transmitted Infections, 2006 edition
and the companion document, Quick Reference:
Canadian STI Guidelines
are available on the web in HTML and PDF format at the
following website: www.publichealth.gc.ca/sti. Hard copies may be available from your
local public health office.
Test your knowledge - True or False?
1. A nucleic acid amplification test (NAAT) can differentiate between LGV and non-LGV serovars of Chlamydia trachomatis. 2. The use of quinolones is always recommended as the preferred treatment for gonorrhea that was not acquired in an Asian country. 3. NAAT is the recommended method of testing for gonorrhea, whether using 4. There is no contraindication for the treatment of external genital warts. 5. Syphilis is only a concern for immigrant populations. Under the coordination of the Public Health Agency of Canada (PHAC), an Expert Working Group (EWG) on sexually transmitted infections (STI) was convened with members from across Canada whose expertise lie in the fields of medicine, nursing, laboratory science, health promotion, public health and research. The EWG and STI experts from across the country voluntarily participated as authors and reviewers to update the 1998 Canadian STD Guidelines. The 2006 edition of the Canadian STI Guidelines provide evidence-based recommendations for the prevention, diagnosis, treatment and management of STI in Canada (Table I). This article was translated from the journal Médecin du Québec, volume 41, numéro 1, janvier 2006, p.35-42, ‘Lignes directrices canadiennes sur les ITS – Édition 2006. Quoi de neuf?’. Ms. Rhonda Y. Kropp works at the Public Health Agency of Canada, Community Acquired Infections Division, in Ottawa. Dr. Marc Steben is a gereral practitioner and works at the Institut national de santé publique du Québec. He also practices at the GMF-CMA (Groupe de médecine de famille – Centre médical associé) at the Clinique médicale de l’ouest, in Verdun, as well as at the Vulvar disease clinic, Hôpital Notre-Dame, Centre hospitalier de l’Université de Montréal. Table I. Summary of Levels of Recommendation and Quality of Evidence Indicators
• Each of the 27 chapters underwent a minimum of four rounds of expert review,
three rounds within the expert working group (EWG) and one round with at least two external reviewers. • Final approval of each chapter was required by each member of the EWG before • Each treatment recommendation in the guidelines has a quality of evidence and strength of recommendation indicator according to a combination of the methodologies from the US Preventive Services Task Force and the Canadian Task Force on Preventive Health Care, as outlined below. Good evidence to support the recommendation (benefit substantially outweighs harm) Fair evidence to support the recommendation (benefit outweighs harm) Fair evidence, but not strong enough to justify a general recommendation Fair evidence that the treatment is ineffective (or harm outweighs benefit) Insufficient evidence (lacking, poor quality, conflicting)
Quality
I
Evidence from at least one randomized, controlled trial Evidence from at least one clinical trial without randomization (cohort, case- control, time-series, dramatic results in uncontrolled experiment)

Changes to the Content of the Old Guidelines

Chapters have been added to the Specific Populations section including Men Who Have Sex With Men (MSM)/Women Who Have Sex With Women (WSW), Substance
Use, Immigrants and Refugees, and Inmates and Offenders. In addition to these new
chapters, changes in content were made for all chapters of the guidelines. This article
outlines some of the changes with highlights from the treatment recommendations.


Lymphogranuloma venereum (LGV)

Given the recent emergence of LGV in Canada2 and internationally3, a chapter has been added on this infection. Table II outlines the LGV treatment recommendations for individuals infected with LGV and their partners. Diagnosis of LGV can be difficult given that some of the symptoms can be present with other STI and other infections or conditions. In Canada, outbreaks of LGV have been found primarily among MSM, with initial symptoms being proctitis or inguinal/femoral lymphadenopathy. Culture and nucleic acid amplification tests (NAAT) do not differentiate between LGV and non-LGV serovars, and positive serology results are suggestive of LGV infection but only in the presence of elevated titres (microimmunofluorescence [MIF] ≥1:256 or complement fixation [CF] ≥1:64). A positive laboratory result by one of these methods requires confirmatory testing using one or two LGV specific tests (restriction fragment length polymorphism [RFLP] or DNA sequencing). For suspected cases of LGV both swab (for NAAT or culture) and sera (for MIF or CF) samples should be submitted for laboratory testing. Suspected cases should be treated empirically for LGV while awaiting test results and given the high rates of co-infection, counselling and testing for other STI, including HIV, hepatitis B and hepatitis C is also recommended. Enhanced surveillance efforts for LGV are underway to help determine the epidemiology of this infection in Canada. It is important to promptly notify your local public health authorities of any suspected cases of LGV. The surveillance protocol and survey instrument are available on the PHAC website at: (English) and (French). LGV has been found primarily among men who have sex with men, with
initial symptoms being proctitis or inguinal/femoral lymphadenopathy.


Table II. Recommended treatment for LGV in Canada

First Choice: Doxycycline 100 mg PO bid for 21 days [B-II] Alternative: Erythromycin 500 mg PO qid for 21 days* [C-III] Possible: Azithromycin 1g PO once weekly for three weeks† [C-III]
Treatment of sexual partners

Sexual partners from the last 60 days should be contacted, tested and treated as follows: • Azithromycin 1g PO in a single dose [C-III] • Doxycycline 100mg PO bid for 7 days [C-III] LGV= lymphogranuloma venereum
*Erythromycin dosage refers to the use of erythromycin base. Equivalent dosages of other formulations
may be substituted. For pregnant women we must use erythromycin. However, the use of erythromycin
estolate is contraindicated.
† While some experts believe azithromycin to be effective in the treatment of LGV, clinical data are
lacking.
Aspiration of buboes may help symptomatically; however incision/drainage or excision of nodes is
not helpful and may delay healing.

Source: Public Health Agency of Canada. Canadian Guidelines on Sexually Transmitted Infections, 2006
Edition
. Ottawa, ON: Public Health Agency of Canada, 2006. Reproduced and adapted with the
permission of Public Works and Government Services Canada.
Gonorrhea

An increased resistance to fluoroquinolones in some strains of N. gonorrhoeæ has resulted in changes to the recommended treatment for gonorrhea4. In Canada, the use of quinolones (i.e. ciprofloxacin and ofloxacin) is no longer recommended for treating gonorrhea-infected patients or their partners who are from, or are epidemiologically linked to areas reporting high rates of quinolone resistance (see Table III for recommendations). The use of quinolones should only be considered if other recommended treatments are not tolerated or available, and only in cases where patients are likely to return for follow up testing as test of cure is recommended to assess response to treatment. Culture remains the recommended laboratory testing method for the diagnosis of gonorrhea. Culture is especially important under the following circumstances: child sexual abuse, sexual assault, clinical evaluation of pelvic inflammatory disease, treatment failure, infection acquired overseas or in regions with reported antimicrobial resistance. Antimicrobial susceptibility testing is suggested for all isolates and is required for all cases where test of cure results are positive and in all cases where there is treatment failure. Nucleic acid amplification testing (NAAT) of urine specimens may be useful for patients who are resistant to pelvic examination or urethral swabbing or who refuse testing. Using NAAT instead of culture is recommended when transport/storage conditions are not conducive to maintaining the viability of N. gonorrhoeæ (consult with your laboratory to determine appropriate methods of specimen collection and transportation). NAAT is approved for cervical and urethral swabs and urine specimens; certain types of NAAT are also approved for vaginal swabs. NAAT is not recommended for test of cure or for detection of possible re-infection less than 3 weeks following completion of treatment. A rise in reported fluoroquinolone-resistant N. gonorrhoeæ resulted in
changes to the recommended treatment for gonorrhea

Table III. Recommended treatment for youth and adults with urethral,
endocervical, rectal or pharyngeal gonorrhea infection in Canada (except in
pregnant and nursing women)

Alternative ONLY if use of quinolones
Preferred
not recommended and cephalosporin
allergy OR immediate/anaphylactic
penicillin allergy

• Azithromycin 2 g PO in a single dose Special Access Program (SAP) [A-I]. OR • Ceftriaxone 125 mg IM in a single All regimens should be followed by empiric treatment for chlamydia:
• Azithromycin 1 g PO in a single dose [A-I] OR • Doxycycline 100 mg PO bid for 7 days [A-I]
*Caution: Quinolones are not recommended if the case or contact are from, or are epidemiologically
linked to any area with rates of quinolone-resistant N gonorrhoeae >3-5%: Asia, Pacific Islands (incl.
Hawaii), India, Israel, Australia, United Kingdom; Regions of the United States (check with the U.S.
Centers for Disease Control and Prevention for rates of quinolone resistance by geographic area); MSM
with contact or epidemiologically linked to the United States; Areas in Canada experiencing high rates of
quinolone resistance – current numbers provided by the National Microbiology Laboratory place Quebec,
Ontario, Alberta and British Columbia above the 3% threshold for quinolone resistance. Please check with
your local public health officials to learn about quinolone resistance in your area. For data on national
quinolone resistance in Canada, please visit the Public Health Agency of Canada website When the use of quinolones are not recommended or in case of a cephalosporin allergy or
immediate and/or anaphylactic reaction to penicillin, use Azithromycin, 2g PO in a single dose [A-I] or
Spectinomycin, 2g IM in a single dose (available only through Special Access Program [SAP]) [A-I].

Source: Public Health Agency of Canada. Canadian Guidelines on Sexually Transmitted Infections, 2006
Edition
. Ottawa, ON: Public Health Agency of Canada, 2006. Reproduced and adapted with the
permission of Public Works and Government Services Canada.


Chlamydia

The treatment recommendations for urethral, endocervical, and rectal chlamydia
infections in youth and adults have been slightly modified from the ones in the 1998 STD
Guidelines. Doxycycline, which was recommended in the past as an alternative to
azithromycin treatment has now been added as a second preferred treatment option given
evidence to support its efficacy (Table IV).

Table IV. Recommended treatment for adults with urethral, endocervical, rectal or
conjunctival chlamydia infection (except in pregnant and nursing women)
Preferred

Alternative
• Azithromycin 1 g PO in a single dose if poor compliance is expected* [A-I] OR • Erythromycin 1 g/day PO in divided * If vomiting occurs more than one hour post administration, a repeat dose is not required.
† Erythromycin dosages refer to the use of erythromycin base. Equivalent dosages of other formulations
may be substituted (with the exception of the estolate formulation which is contraindicated in pregnancy).
If erythromycin has been used for treatment, test of cure should be performed 3 to 4 weeks after completion
of therapy.

Source: Public Health Agency of Canada. Canadian Guidelines on Sexually Transmitted Infections, 2006
Edition
. Ottawa, ON: Public Health Agency of Canada, 2006. Reproduced and adapted with the
permission of Public Works and Government Services Canada.

Syphilis

Over the last three years, outbreaks of syphilis have been reported both in Canada and
worldwide resulting in a need for increased screening, especially among high risk
populations. Screening for syphilis involves the use of non-treponemal tests (NTT), for
example Venereal Disease Research Laboratory (VDRL), followed by confirmatory
treponemal tests if the NTT is reactive. In patients with suspected primary syphilis or late
latent syphilis, the NTT may be non-reactive in which case it is appropriate to add a
treponemal test to the initial screen, or in the case of primary syphilis, to repeat the NTT
after 2-4 weeks. In regions experiencing outbreaks of syphilis it may be appropriate to
screen at baseline with both non-treponemal and treponemal tests. The revised guidelines
provide a new guide for the interpretation of serological tests for syphilis (Figure V).
Benzathine penicillin G is still the treatment of choice. It is available only through
provincial/territorial Ministries of Health which obtain the drug from non-Canadian
pharmaceutical companies through Health Canada’s Special Access Program (SAP).
Table V. Interpretation of serologic tests for syphilis
Non-
Treponemal
Treponemal
Treponemal
Most likely condition
RPR, VDRL
Non-reactive
Primary syphilis with compatible history/clinical findings • Follow-up of treated syphilis OR • In persons from endemic countries, yaws (e.g. Caribbean), pinta (e.g. Central America) or bejel • Usually treated syphilis OR • Late latent of unknown duration if no history of confirmed treatment countries, yaws (e.g. Caribbean), pinta (e.g. Central America) or bejel Biological false positive* (repeat in 3-4 weeks) FTA-ABS= fluorescent treponemal antibody absorbtion test
RPR= rapid plasma reagin
TP-PA= T. pallidum particle agglutination
VDRL= Venereal Disease Research Laboratory
*Some causes of false positive serologic tests for syphilis include certain collagen vascular diseases,
pregnancy and injection drug use.

Source: Public Health Agency of Canada. Canadian Guidelines on Sexually Transmitted Infections, 2006
Edition
. Ottawa, ON: Public Health Agency of Canada, 2006. Reproduced and adapted with the
permission of Public Works and Government Services Canada.
Genital Herpes

As summarized in Table VI, treatment for genital herpes is recommended for clinically
significant symptoms. In addition to the recommendations listed below, the
recommended treatment for severe primary episodes is: infused IV acyclovir 5 mg/kg
over 60 minutes every 8 hours [A-I], with step down to oral therapy when clinical
improvement has occurred. To be effective, treatment needs to be started as early as
possible during the development of a recurrent lesion - preferably fewer than 6 hours
(famciclovir) [B-I] to 12 hours (valacyclovir) [B-I] after the first symptoms appear.
Suppressive therapy is intended for patients with frequently recurring genital herpes,
generally for those with recurrences at least every 2 months or 6 times per year. For
patients with fewer recurrences, episodic therapy is recommended (Table VI). For
pregnant women, treatment with acyclovir has been shown to be effective in reducing
recurrences, asymptomatic shedding, and the need for cesarean section, but does not
completely eliminate maternal-to-child transmission of herpes simplex virus (HSV).

Table VI. Recommended treatment for herpes simplex virus (HSV) in Canada
First episode

Recurrent episodes
Suppressive therapy

Non-pregnant women:
[A-I] (for patients with more than nine recurrences per year) Pregnant women:
• Acyclovir 200 mg qid [A-I] OR • Acyclovir 400 mg tid [A-I]
Source: Public Health Agency of Canada. Canadian Guidelines on Sexually Transmitted Infections, 2006
Edition
. Ottawa, ON: Public Health Agency of Canada, 2006. Reproduced and adapted with the
permission of Public Works and Government Services Canada.
Human papillomavirus (HPV) Infections

The revised Canadian STI guidelines contain new recommendations for self-administered
treatment of external genital warts for men and women (Table VII). All treatments are
associated with local skin reactions which can be managed by decreasing the intensity of
the treatment. Efficacy rates are difficult to determine due to lack of uniformity in clinical
trials. Even though the recurrence rate is high (60%), the podofilox/podophyllotoxin
0.5% solution is more efficacious, more stable and is associated with fewer side-effects
than the podophyllin treatment carried out in the medical office. In Canada, this product
is available in two brands, Wartec™ and Condyline™; both contain the same medication,
however, the former comes with a plastic applicator and the latter with a cotton swab.
This product should not be used by pregnant women or by women who are not using a
highly effective and reliable method of contraception. In addition these treatments
should not be used for cervical, meatal, vaginal or anal condyloma.
Imiquimod (Aldara™) can be used as a first line treatment for HPV as well as for
refractory cases. Recurrence rates (10%) with this product are lower than those for all
other types of treatment. Imiquimod acts as an immune modulator. It is not considered to
be safe for use during pregnancy and should not be used by pregnant women.
For HPV, all treatments of external genital warts are associated with
skin reactions which can be managed by decreasing the intensity of the
treatment. Efficacy rates are hard to determine due to lack of
uniformity in the clinical trials.


Table VII. Recommendation for self-treatment of external genital warts (except
during pregnancy)

• Self-application of a podofilox/podophyllotoxin 0.5% solution (Wartec™, Condyline™) under the direction of a physician. Apply to warts every 12 hours for 3 consecutive days of each week, avoiding surrounding skin. The cycle can be repeated for up to 6 weeks with the total dose per day not to exceed 0.5 mL [A-I]. • Imiquimod (Aldara™) self-application, 3 times a week, for up to 16 weeks. Leave at least one day between applications. Wash off after 6-8 hours [A-I].
Source: Public Health Agency of Canada. Canadian Guidelines on Sexually Transmitted Infections, 2006
Edition
. Ottawa, ON: Public Health Agency of Canada, 2006. Reproduced and adapted with the
permission of Public Works and Government Services Canada.

Epididymitis
Finally, a recent review of the latest data has resulted in significant changes to the
recommended treatment for Epididymitis (see Table VIII).
Table VIII. Canadian treatment recommendations for epididymitis
Epididymitis caused by chlamydial or gonococcal infections

• Ceftriaxone 250 mg IM in a single dose [A-I] • Ciprofloxacin 500 mg PO in a single dose [A-I] (unless not recommended due to quinolone resistance – see Table III for gonococcal infections recommendations) • Doxycycline 100 mg PO bid for 10-14 days [A-I] Epididymitis caused by enteric organisms
• Ofloxacin 200 mg PO bid for 14 days [A-I]
N.B. Cefixime is no longer a recommended treatment.
Source: Public Health Agency of Canada. Canadian Guidelines on Sexually Transmitted Infections, 2006
Edition
. Ottawa, ON: Public Health Agency of Canada, 2006. Reproduced and adapted with the
permission of Public Works and Government Services Canada.

This article outlines only a small proportion of the recommendations outlined in the
Canadian Guidelines on Sexually Transmitted Infections 2006 Edition. You can access
more information on these Guidelines at the follow (English) or (French).
References
1. Public Health Agency of Canada. Canadian Guidelines on Sexually Transmitted
Infections, 2006 Edition. In Press, 2006.
2. Kropp RY, Wong T on behalf of the Canadian LGV Working Group. Emergence of
lymphogranuloma venereum in Canada. CMAJ 2005; 172 (13): 1674-6.
3. van de Laar MJW, Fenton KA, Ison C, on behalf of the ESSTI network. Update on the
European lymphogranuloma venereum epidemic among men who have sex with men.
Eurosurveillance 2005; 10 (6).
4. Mann J, Kropp R, Wong T, Venne S, Rowmanowski B; Expert Working Group for the
Canadian STI Guidelines. Gonorrhea treatment guidelines in Canada: 2004 update.
CMAJ 2004; 171 (11): 1345-6.
Note: Complete references for all diagnosis, treatment, and management
recommendations for each infection listed in this article are found in the Canadian
Guidelines on Sexually Transmitted Infections,
2006 Edition.

Source: http://www.atlantique.phac.gc.ca/std-mts/pdf/whatsnew-quoineuf_e.pdf

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