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1
Q

What is the cause of traveller’s diarrhea?

A

Parasites, bacterium or viruses

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2
Q

What are some of the organisms that cause traveller’s diarrhea in rich countries?

A

Enteroviruses, enterotoxigenic E. coli
(ETEC), non-typhoidal Salmonella spp, Campylobacter spp, Giardia, and
Cryptosporidium

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3
Q

What are some of the organisms that cause traveller’s diarrhea in poor countries?

A

Entamoeba, Shigella, Salmonella Typhi and Paratyphi, and Vibrio cholerae

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4
Q

Why is it difficult to diagnose traveller’s diarrhea once they have returned home?

A

Most people experience such mild diarrhea/self limiting that they would not go to the Doctor.
A sample may not be taken
Difficult to identify the causative organism

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5
Q

What are some of the risk factors of traveller’s diarrhea?

A

Those travelling from a rich to a poor country (20-50% affected)
The young
The elderly
Those with special needs

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6
Q

How is traveller’s diarrhea caused?

A

Under-cooked food
Food left out for some time
Contaminated liquid

or diarrhea caused by stress, a change in diet, increased alcohol consumption and hot weather

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7
Q

What are the main indicative symptoms of traveller’s diarrhea?

A

3 loose stools in 24 hours
or any number of stools accompanied by abdominal pain, nausea or vomitting
Normally starts in the first week of arrival and last 3-4 days

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8
Q

Who can’t take loperamide?

A

If the traveller has active ulcerative
colitis, a fever or bloody diarrhoea. Loperamide should be used with caution and
only under specialist supervision in children under the age of 12 years.

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9
Q

Which antibiotic is recommended to be taken alongside loperamide?

A

Ciprofloxacin (500mg) as a single dose

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10
Q

If oral rehydration powders aren’t available what is recommended?

A

A salt and sugar solution of 8 level teaspoons of sugar and ½ teaspoon of salt to a litre of clean water.

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11
Q

When should the patient refer to a Doctor for traveller’s diarrhea?

A

If symptoms do not improve within a few
days, they are passing blood and/or mucous, or develop a fever

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12
Q

How does prickly heat occur?

A

When the sweat glands become blocked.

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13
Q

How can prickly heat be treated?

A

First generation anti-histamine

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14
Q

Who is most at risk of heat exhaustion?

A

Elderly
Those exercising in the sun
Patients with high blood pressure

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15
Q

What are some of the symptoms of heat exhaustion?

A

Heavy sweating, tiredness, headache,
nausea and vomiting and fainting.

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16
Q

How can heat exhaustion develop into a medical emergency?

A

If fluids are not replaced and the core body temperature is reduced

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17
Q

How does photo sensitivity occur?

A

When certain drugs are ingested or agents
applied to the skin and then exposed to visible light or UV radiation

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18
Q

What conditions can be benefited by UV radiation?

A

Psoriasis and topical skin sensitivities as it induces immunosupression in localized tissue

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19
Q

List 4 sunscreen advice points you would provide to patients.

A

Sunscreens should have a broad spectrum protection against UVB and
UVA
They should have a minimum SFP of 15 and a four star rating (giving 90%
protection against UVB)
Even in the UK they should avoid peak radiation levels between 11am
and 3pm
They should apply sunscreen 30 minutes before exposure to strong
sunlight and re-apply frequently: never allow the skin to burn and only
use “in date” preparations

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20
Q

When can deep vein thrombosis occur whilst travelling?

A

In any period of long inactivity such as a long flight, road trip

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21
Q

What is the main symptom of a pulmonary embolism?

A

Getting very short of breath, chest pain, coughing up blood, sudden collapse

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22
Q

List 5 methods of reducing the risk of developing DVT whilst travelling.

A

Avoid dehydration
Wear non-restrictive clothing
Try to walk around as much as possible
Wearing fitted compression socks of 15 to 30mmHg of pressure to the legs
Regularly flexing and extending the ankle

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23
Q

Which groups of people would be contra-indicated against receiving booster travelling vaccines?

A

Pregnant women with live vaccines (unless advised otherwise).
Influenza and yellow fever vaccines should not be given to those with a
confirmed anaphylactic reaction to egg protein
Anybody who suffered with a severe anaphylaxis to previous antigen vaccine
Acutely unwell patients

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24
Q

Four pieces of travelling advice for those with existing medical conditions?

A

They should tell their travel insurer about the condition
 Ask their doctor how the trip might affect them
 Carry a doctor’s letter and a copy of any prescription
 Learn key words and phrases in local languages for the condition,
medication and emergency help

In addition ensure their medication is legal in the country they are travelling to

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25
Where can the appropriate information be found on taking controlled drugs abroad?
The Home Office website has embassy details
26
What is the risk of a diabetic patient contracting malaria?
May result in hypoglycemia and loss of consciousness
27
If a diabetic patient is travelling through more than 5 time zones what considerations should they make?
If travelling east- the day will be shorter therefore need to reduce insulin tablets and carbohydrate intake If travelling west- day will be longer therefore need to increase insulin tablets and carbohydrate intake
28
If somebody has not got a functioning spleen where should they not travel?
Malaria countries
29
Which anti-malarial drugs can epileptics not take?
Chloroquine and mefloquine as they can cause seizures
30
What drugs reduce doxycyclines half life?
Barbiturates, carbamazepine and phenytoin
31
Apart from epileptic which other patients cannot take mefloquine?
Those with a history of depression or anxiety. Patients with cardiac arrhythmias or those taking anti-arrhythmic drugs or beta-blocker
32
What anti-malarials are safe to be taken during pregnancy?
Chloroquine and proguanil are considered safe in pregnancy (even though less effective), as is mefloquine in the second and third trimester
33
When should mefloquine not be taken by the Mother and infant?
If the baby weighs under 7kg (and is still breast-fed)
34
If patients are taking anti-coagulants what should they do to prepare to travel?
They should stick to a regime 3 weeks before travelling so their INR is stabilised
35
Which drugs can increase the effects of warfarin?
Proguanil and doxycycline
36
How can a patient with respiratory disease prepare to travel?
As travel can cause exacerbated symptoms of respiratory disease particularly secondary chest infection in COPD ensure influenza and pneumonia vaccines are kept up to date. Contact airlines to ensure additional oxygen supplies are available during flight as it can cause hypoxia in those with cardio-pulmonary disease.
37
Which condition may add to the haemolysis cause by malaria?
Thalassaemia and sickle cell disease
38
Is chloroquine suitable for G6PD deficiency?
It can cause red cell damage but prophylatic doses are too low to have an effect
39
Is doxycycline suitable in for Acute porphyrias?
No it is contra-indicated
40
Which demographics are more prone to experience symptoms of motion sickness?
Women especially when on their period Those who suffer from migraines Children aged 3-12 years old
41
What are some of the symptoms of motion sickness?
Drowsiness Cold sweats Nausea and vomiting Pallor and fainting
42
How can the symptoms of motion sickness be prevented?
Focusing on a fixed point in the horizon Lying horizontally Avoid looking down Avoid a stuffy environment
43
What are some of the OTC medications for motion sickness?
Cyclizine (Valoid) 50mg 4 to 6 hrs Hyoscine tablets (Scopolamine) 0.3 - 0.6mg 4 to 6 hrs Promethazine (Avomine) 25mg 24 to 30 hrs Meclizine (Sealegs) 25mg 6 to 12 hrs Cinnarizine (Stugeron) 30mg 6 to 8 hrs
44
How does hyoscine work?
By blocking some of the nerve signals sent from the vestibular system to the inner ear which can cause nausea
45
What the indications for hyoscine patches?
Suitable for 10 years and above To be applied before travelling and changed every 3 days
46
Can you take hyoscine before driving?
No because it can cause side effects such as blurred vision and drowsiness
47
What are some of the other side effects of hyoscine?
dry mouth dizziness constipation Rarer side effects include: nausea vomiting mental confusion, particularly in elderly people
48
When should hyoscine be used with caution?
In children In the elderly Those with kidney or liver problems Those with heart problems Those with a history of gastro-oesophageal reflux disease
49
Which three anti-histamines are recommended for motion sickness?
Promethazine Cyclizine Cinnarizine
50
What are some of the side effects of these anti-histamines?
Drowsiness headaches Pins and needles Dry mouth Blurred vision
51
What other non-pharmacological treatments be recommended for motion sickness?
Eating ginger Acupressure bands
52
At what altitude does acute mountain sickness occur?
2500-3000m normally but it can occur from 1500m upwards
53
At what point does acute mountain sickness occur?
6-12 hours after arriving at the altitude symptoms can begin to occur but it can be as delayed as 24 hours after
54
Is acute mountain sickness dangerous?
No in most cases the symptoms are self-limiting (do not last more than 1/2 days if further ascent does not occur). However in 10% of cases it can develop to high-altitude cerebral oedema and possibly high-altitude pulmonary oedema which are life threatening and person should descend immediately.
55
What are the key symptoms of acute mountain sickness?
Headache, fatigue, loss of appetite and nausea.
56
What are the key symptoms of high-altitude cerebral oedema?
Lethargy, confusion and ataxia (poor muscle control) in addition of acute mountain sickness symptoms.
57
What are the key symptoms of high-altitude pulmonary oedema?
Shortness of breath (which develops to even at rest) and dry cough
58
What is the recommended treatment of acute mountain sickness?
Paracetamol, ibuprofen, aspirin to relieve headache Anti-emetics for sickness Do not leave the person unattended in case symptoms progress If symptoms do not improve descend by 500m-1000m
59
Which vaccination proof is essential for Hajj and Umrah pilgrimages?
Vaccination proof of the quadrivalent vaccine against meningitis which has been issued not more than 3 years and no less than 10 days prior to arrival in Saudi Arabia.
60
Which other vaccinations are recommended for Hajj and Umrah pilgrimages?
Seasonal influenza vaccines 5 doses of tetanus vaccine 5 doses of polio vaccine (more than 10 years requires a booster) MMR vaccine
61
What are some of the effects of jet lag?
Sleep disturbance, loss of appetite, nausea and sometimes vomiting, bowel changes (e.g. constipation), general malaise, tiredness and poor concentration
62
List 5 ways jet lag can be prevented.
On arriving take sleeping tablets Taking regular melatonin Breaking up long journeys Drinking lots of water Stretch and exercise as much as possible to avoid swollen ankles
63
When do signs of rabies begin to appear?
20-90 days after being infected
64
What the first symptoms of rabies?
Fever, head and muscle ache · Extreme tiredness. · Numbness and tingling can occur at the site of the bite/scratch.
65
List 3 symptoms of furious rabies.
Seizures Hyperactivity Confusion
66
How do you die from rabies?
After the symptoms of furious rabies has developed, additional symptoms such as throat spasms, inability to drink also develops. Eventually you lose control of muscles and are paralyzed from the site of the bite/ scratch across the body until you fall into a coma and then death.
67
How many people die each year from rabies?
50,000 and 60,000 people
68
How many vaccines are needed for rabies?
3 to be taken at least 21 days before travel
69
When is the rabies vaccine recommended?
You live, travel frequently to or spend long periods in countries with rabies. · You cycle or run in risk areas. · Your work puts you at risk.
70
What is dengue fever?
A viral illness spread by day-biting mosquitoes.
71
What are some of the symptoms of dengue fever?
Fever * Intense joint and muscle pain * Nausea and vomiting * Red rash Severe headache
72
Where is dengue fever most common?
Africa, Asia, the Caribbean, Central and South America and the Western Pacific
73
How can dengue fever be treated?
Paracetamol, ibuprofen - to relieve pain Rest Drinking plenty of fluids
74
What are the red flag symptoms of dengue?
Tiny bloods spots or large patches of blood under your skin, bleeding from the gums or nose, persistent vomiting and severe abdominal pain, vomiting blood or black, tarry stools indicate dengue hemorrhagic fever.
75
What are the four species of Plasmodium parasite that causes malarial infection in humans?
P. falciparum, P. vivax, P. ovale and P. malariae
76
How do the four species of plasmodium differ?
They differ in their life cycle, clinical manifestations and morphology (structural features).
77
Where is p. vivax most common?
South America and Southeast Asia
78
Where is p. vivax dormant?
In the liver and can be reactivated after months leading to the attack of blood stage
79
Which stage do most anti-malarials target?
Human blood stage
80
What is the role of gametocytes in malarial transmission?
Gametocytes are the sexual form of the parasite which can be formed when the parasite is in an infected person's blood. They draw up the infected blood infecting the parasite and hence continuing the cycle.
81
Describe the asexual stage of malaria.
The female Anopheles mosquito injects sporozoites into the blood stream of the patient. Sporozoites are then rapidly uptaken by hepatocytes. Parasites develop and form schizonts from which several thousand merozoites form. Hepatocytes rupture releasing merozoites into the bloodstream rapidly destroying the red blood cells. Clinical symptoms of malaria begin.
82
Describe the sexual stage of malaria.
A small percentage of merozoites, differentiate into male and female gametocytes, which are taken up by the mosquito in her blood meal. These infect the parasite which then infects the next person. Male and female gametocytes fuse within the mosquito forming diploid zygotes, which in turn become ookinetes. Ookinetes migrate to the midgut of the insect, pass through the gut wall and form oocysts. Meiotic division of oocysts form sporozoites are formed, which then migrate to the salivary glands of the female Anopheles mosquito.
83
When do symptoms of malaria usually occur?
10-15 days after bite
84
What are some of the clinical symptoms of malaria?
a high temperature (fever) of 38°C (100.4F) or above  sweats and chills  generally feeling unwell  muscle pains  headaches  cough  diarrhea
85
What are some of the complications of malaria?
breathing problems (fluid in the lungs)  liver failure and jaundice  shock  spontaneous bleeding  abnormally low blood sugar  kidney failure  swelling and rupturing of spleen  dehydration
86
Which type of plasmodium causes cerebral malaria?
P. falciparum (also causes kidney damage)
87
How can malaria be treated?
Targetting the mosquito (DTT insecticide) Targeting the erythocytic stage
88
What do anti-folates target?
The cell cytosol
89
How do anti-folates work?
Antifolate antimalarial drugs interfere with folate metabolism, a pathway essential to malaria parasite survival, they prevent the biosynthesis of amino acids and nucleotides
90
What are the specific targets of anti-folate metabolism?
De novo biosynthesis of folates and dihydrofolate reductase
91
What class of drug is Proguanil?
Dihydrofolate reductase inhibitor
92
What is proguanil combined with usually?
Atovaquone which is sold under the tradename Malarone
93
How does Atovaquone work?
Selectively inhibits the parasitic mitochondrial electron transport chain
94
Why is anti-malarials targetting the food vacuole a good drug target?
The food vacoule is required by the parasites for the digestion of haemoglobin which provides the parasite with the amino acids required for its own protein synthesis.
95
What proteases are found in the food vacuole?
Plasmepsins (aspartic acid protease) - Falcipains (cysteine protease) - Falcilysins (metallo protease)
96
How do parasites detoxify the toxic heme group released through the digestion of haemoglobin?
Sequestration of the free heme into hemozoin, or the malarial pigment (so called because it has an intense purple colour) - Degradation facilitated by hydrogen peroxide within the food vacuole - Glutathione-dependent degradation which occurs in the parasite's cytoplasm
97
How does quinoline accumlate in the food vacuole?
This accumulation may involve ion trapping following protonation, specific transport, and/or binding to a receptor (eg. heme)
98
What can traveller's do to prevent malaria?
Loose fitting clothing Repellents on exposed skin Mosquito nets
99
What should the Pharmacist advise patients with young children travelling to malarious countries?
Young children under 5 are more likely to suffer from complications from malaria. Instruct the parent to protect the children from insect bites and that they should be given malaria chemoprophylaxis. Malaria chemoprophylaxis doses should be given according to body weight/ age group
100
What should be covered in collecting a medical history for somebody travelling to a malarious country?
Full history for each traveller Any special needs that may be affected by foreign travel Check traveller’s medication for possible interactions and contraindications with malaria prophylaxis or live vaccines Travelling affects administration schedules, as well as the storage and transportation of refrigerated medication such as insulin
101
Can pregnant women travel to malarious countries?
No it should be avoided and if they are trying to conceive
102
Which class of drug's does doxycycline reduce the effectivity of?
Contraceptives
103
Why should you ask about date of travel, transport and destination details?
Chemoprophylaxis doses need to be given at a suitable time Urban areas are better protected from malaria Prolonged periods of inactivity, dehydration and pre-existing risk factors can increased the risk of deep vein thrombosis during travel
104
How much protection does 50% DEET have?
Up to 12 hours
105
How much protection does 20% DEET have?
1-3 hours
106
What does DEET reduce the efficacy of?
Sunscreen, but not the other way round
107
What are two alternatives to DEET?
Lemon eucalyptus and picaridin
108
What stage does casual prophylaxis target?
The liver stage and it prevents progression to the erythrocytic stage of infection
109
Where does Suppressive prophylaxis act?
Erythrocytic stage of infection and continues for 28 days after
110
What treatment is used for relapsing malaria?
Primaquine or tagenoquine

Infections (16 decks)

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