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This is fol- Cannabis resin production is geographically more lim- lowed by a regional overview order 125mg keftab with visa antibiotic resistance funding. Based on information on the origin of cannabis on specific drug markets (opiates order 375mg keftab with amex antibiotics for dogs buy online, cocaine purchase prandin 0.5mg with visa, cannabis and resin, supplied by Member States, this seems to take amphetamine-type stimulants) can be found in subse- place primarily in Morocco – mainly producing for the quent chapters. Moroccan authorities report that cannabis resin produc- a) Production tion has declined in recent years. The second largest ally stable level in 2010, compared to a year earlier illicit drug production is related to cocaine, followed by (which was 1,500-3,500 mt in 2009). Amphetamine-type stimulants production seems to be at comparable levels with heroin. Information on production is more readily available Cannabis – the most widely produced illicit drug when it comes to heroin and cocaine. These surveys showed clear declines over the cannabis, in contrast, is concentrated in developed 2007-2009 period (-21% for opium and -13% for coca). Between 2007 and 2010, 8,000 6,610 potential cocaine production shrank by about one sixth, 7,000 reflecting strongly falling cocaine production in Colom- 6,000 4,7834,850 4,860 bia which offset increases identified in both Peru and the 5,000 4,520 4,620 Plurinational State of Bolivia. The increase was mainly linked to methamphetamine The downward trend for the area under opium poppy laboratories dismantled in the United States of America. The global area under opium sor chemicals (ephedrine and pseudoephedrine), taken cultivation in 2010 amounted to some 195,700 ha, which was still some 12% lower than in 2000 and more together, more than doubled in 2009. Afghanistan contin- In contrast, the number of amphetamine and ecstasy ued to account for the bulk of the cultivation with some laboratories dismantled globally was lower in 2009 than 123,000 ha (63% of the global total). Seizures of the main In terms of production, opium output declined strongly amphetamine and ecstasy precursors fell in 2009. The in 2010 (-38%) due to a massive decline of opium pro- importance of Europe as a key location for the manufac- duction in Afghanistan (-48%) linked to much lower ture of ecstasy continued to decline. In parallel, the importance of Myanmar increased, from 5% of total opium produc- 10,000 100 tion in 2007 to 12% in 2010. Given the declines of opium production in Afghanistan, global opium pro- 8,000 80 duction declined by 45% between 2007 and 2010. These calculations, however, do not take into account the stock and inventory of opium. Based - 0 on consumption estimates and the amounts seized, it is 1 The figure for the Plurinational State of Bolivia was not available at the time of printing of this report. The total area under cultivation 2007 in 2010 is based on 2009 figures for Bolivia and will be revised when 2008 the 2010 figure becomes available. Some 160 mt of Afghan heroin are estimated Trafficking flows continue to show distinct patterns: to have entered Pakistan in 2009 of which the bulk (some 138 mt) were for final destinations in Europe, • Most of the cannabis herb trafficking is intra-regional.

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Where causative/precipitating factors cannot be detected purchase keftab 125 mg amex antibiotic resistant bacterial infection, the following treatments may be offered: For Non-productive irritating cough A: Cough syrup/Linctus (O) 5-10 ml every 6 hours Expectorants may be used to liquefy viscid secretions buy discount keftab 250mg line antibiotics for acne beginning with t. A: Cough expectorants (O) 5-10 ml every 6 hours Note: Antibiotics should never be used routinely in the treatment of cough 5 generic 20mg adalat. Some investigations must be ordered:  Serum glucose level  Serum electrolyte  Pregnancy test for women of child bearing age. Therefore, the following are primarily assessed in children:  Prolonged capillary filling (more than 3 seconds)  Decreased pulse volume (weak thread pulse)  Increased heart rate (>160/minute in infants, > 120 in children)  Decreased level of consciousness (poor eye contact)  Rapid breathing  Decreased blood pressure and decreased urine output are late signs and while they can be monitored the above signs are more sensitive in detecting shock before irreversible. Table 2: Types of Shock Type of Shock Explanation Additional symptoms Hypovolemic Most common type of shock Weak thread pulse, cold Primary cause is loss of fluid from circulation due and clammy skin. Cardiogenic Caused by the failure of heart to pump Distended neck veins, shock effectively e. Septic shock Caused by an overwhelming infection, leading to Elevated body vasodilatation. Anaphylactic Caused by severe allergic reaction to an allergen, Bronchospasm, shock or drug. Intravenous fluid therapy is important in the treatment of all types of shock except for cardiogenic shock. Ringer-lactate, within 48 hours of administering ceftriaxone  Contra-indicated in neonatal jaundice  Annotate dose and route of administration on referral letter. There are three types of dehydration: hypotonic or hyponatremic (primarily a loss of electrolytes, sodium in particular), hypertonic or hypernatremic (primarily a loss of water), and isotonic or isonatremic (equal loss of water and electrolytes). In humans, the most commonly seen type of dehydration by far is isotonic (isonatraemic) dehydration which effectively equates with Hypovolemic, but the distinction of isotonic from hypotonic or hypertonic dehydration may be important when treating people who become dehydrated. Physiologically, dehydration, despite the name, does not simply mean loss of water, as water and solutes (mainly sodium) are usually lost in roughly equal quantities to how they exist in blood plasma. In hypotonic dehydration, intravascular water shifts to the extra vascular space, exaggerating intravascular volume depletion for a given amount of total body water loss. The former can lead to seizures, while the latter can lead to osmotic cerebral edema upon rapid rehydration. It defines water deficiency only in terms of volume rather than specifically water. Signs and symptoms Symptoms may include headaches similar to what is experienced during a hangover, a sudden episode of visual snow, and dizziness or fainting when standing up due to orthostatic hypotension. Untreated dehydration generally results in delirium, unconsciousness, swelling of the tongue and, in extreme cases, death. In the presence of normal renal function dehydration is associated usually with a urine output of less than 0. Differential diagnosis 12 | P a g e In humans, dehydration can be caused by a wide range of diseases and states that impair water homeostasis in the body.

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In pregnant women purchase keftab with visa antibiotics for uti cvs, poorly controlled asthma increases the risk of pre-eclampsia buy keftab 750 mg without a prescription music infection, eclampsia buy discount cephalexin 250mg online, haemorrhage, in utero growth retardation, premature delivery, neonatal hypoxia and perinatal mortality. Long-term treatment remains inhaled salbutamol and beclometasone at the usual dosage for adults. If symptoms are not well controlled during a period of at least 3 months, check the inhalation technique and adherence before changing to a stronger treatment. If symptoms are well controlled for a period of at least 3 months (the patient is asymptomatic or the asthma has become intermittent): try a step-wise reduction in medication, finally discontinuing treatment, if it seems possible. If the patient has redeveloped chronic asthma, restart long-term treatment, adjusting doses, as required. In immunocompetent patients, the pulmonary lesion heals in 90% of cases, but in 10%, patients develop active tuberculosis. Tuberculosis may also be extrapulmonary: tuberculous meningitis, disseminated tuberculosis, lymph node tuberculosis, spinal tuberculosis, etc. Clinical features Prolonged cough (> two weeks), sputum production, chest pain, weight loss, anorexia, fatigue, moderate fever, and night sweats. The most characteristic sign is haemoptysis (presence of blood in sputum), however it is not always present and haemoptysis is not always due to tuberculosis. If sputum is smear-negative, consider pulmonary distomatosis (Flukes, Chapter 6), melioidosis (Southeast Asia), profound mycosis or bronchial carcinoma. In an endemic area, the diagnosis of tuberculosis is to be considered, in practice, for all patients consulting for respiratory symptoms for over two weeks who do not respond to non-specific antibacterial treatment. Treatment The treatment is a combination of several of the following antituberculous drugs [isoniazid (H), rifampicin (R), pyrazinamide (Z), ethambutol (E), streptomycin (S)]. The regimen is standardised and organized into 2 phases (initial phase and continuation phase). Only uninterrupted treatment for several months may lead to cure and prevent the development of resistance, which complicates later treatment. It is essential that the patient understands the importance of treatment adherence and that he has access to correct case management until treatment is completed. Diseases, such as malaria, acute otitis media, upper and lower respiratory tract infections, etc. Treatment General principles: – Prevent or treat dehydration: rehydration consists of prompt replacement of fluid and electrolyte losses as required, until the diarrhoea stops. However, for treating cholera, the administration of a single dose should not provoke any adverse effects. Bloody diarrhoea (dysentery) – Shigellosis is the most frequent cause of dysentery (amoebic dysentery is much less common). If there is no laboratory diagnosis to confirm the presence of amoebae, first line treatment is for shigellosis.

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The current legal status of psychedelic drugs in plant form is some- what ambiguous and confusing buy keftab 125mg on-line bacteria en el estomago. This refects the obvious practical problems of attempting to prohibit access to naturally occurring plants purchase keftab 500 mg amex antibiotics for pink eye, or determining precise criteria for the point at which the owner of the plant/drug becomes the subject of punitive sanctions buy sumycin 250mg cheap. Article 32 of the 1971 convention itself does provide an additional exemption: A State on whose territory there are plants growing wild which contain psychotropic substances from among those in Schedule1 and which are traditionally used by certain small, clearly deter- mined groups in magical or religious rites, may, at the time of signature, ratification or accession, make reservations concerning these plants, in respect of the provisions of article 7, except for the provisions relating to international trade. A number of such exceptions have been implemented and exist in domestic law, providing a functioning legal model for ritual/sacra- mental use of psychedelics. There are clearly lessons for wider regulatory models to be learnt from traditional ritual use. Such use operates within well established social/ cultural controls, ensuring that use is only very occasional, and that set and setting are clearly delineated through careful ritualised preparation. Under such a model, users are very well informed and organised; it is supported by mentoring and peer guidance, with a corresponding respect for the potentially profound and intense nature of the drug experience. For users seeking the more exploratory psychedelic experience, a group/society/club type model could be based on some of the lessons 149 1 2 3 Introduction Five models for regulating drug supply The practical detail of regulation of traditional ritual use. Proposed discussion model for regulation of psychedelics b a s i c r e g u l a t o r y m o d e l > A membership based psychedelic group/club model that would combine elements of the specialist pharmacist model (a trained and licensed vendor with specifc responsibilities), licensed premises for sale and consumption, and licensed users (a membership system with a requirement for training, and potentially meeting certain health criteria). Price controls > The existing illicit market for psychedelics is relatively small, with prices low enough, and use generally infrequent enough, for price to not be an important factor in using decisions—so the usefulness of price controls as a regulatory tool would be marginal. Packaging controls > Supply of psychedelic drugs for use in licensed premises would not require specifc packaging controls. They might also be licensed to administer benzodiazepines, which dampen or negate intense psychedelic related distress. Volume sales/rationing controls > If sales are for onsite supervised use, rationing is not an issue, as the drugs are dispensed for immediate use direct to the user by the vendor (consumption can be supervised). Degree of intoxication/mindset of purchaser/user > Vendors would be required to refuse sales to those clearly intoxicated, according to a clear set of guidelines. Licences/membership requirements for purchasers/users > Access to membership of a psychedelic club/group could be conditional on participation in training sessions to establish a clear understanding of the potential positive and negative effects of different forms of psychedelic use, stressing the importance of set and setting, risks and responsibilities, etc. How such criteria could be 152 4 5 6 Making a regulated system happen Regulated drug markets in practice Appendices objectively evaluated and implemented without being discriminatory or inconsistent is problematic; perhaps the best option would be for appropriate questions to be built into an informal membership interview (potentially also used to establish that training was adequate). Relevant information would, however, have to be volunteered (unless a requirement for a doctor’s ‘all clear’ was mandated). Once a member had established themselves as a responsible, informed and non-problematic user over a certain period they could then potentially graduate to being able to take out supplies for personal use. Pharmacy sales model A licensed user/pharmacy-sales model could operate for certain psychedelics, potentially alongside a group model described above. This could either be for already established group members, or allow access based on a similar training/vetting process. Lower threshold licensed sales for psilocybin (‘magic’) mushrooms Psilocybin or ‘magic’ mushrooms are distinct from the other psyche- delics discussed here in some key respects. They are generally shorter 94 acting and, unlike peyote, San Pedro cacti and ayahuasca, they are 95 consumable in their raw form without any preparation.