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Median follow up time from reconstruction 400 mg albenza fast delivery medications for bipolar disorder, of those who survived cheap albenza 400mg with mastercard treatment vitamin d deficiency, was 111 months (29-134 months) discount albenza 400mg amex medicine 7 years nigeria. Conclusion Our data has demonstrated no difference in cancer specific survival or recurrence rates in patients who underwent mastectomy with immediate breast reconstruction compared buy albenza 400 mg amex symptoms your dog is sick patients who had delayed reconstruction. Body: Background:Immediate breast reconstruction following mastectomy is a key quality metric of a comprehensive breast cancer program. Fat grafting has been found be a safe and effective adjunct standard breast reconstructive techniques. Fat graft only breast reconstruction has been reported, but in conjunction with external suction based tissue expansion. Dermatocutaneous flaps have been described for immediate breast reconstruction, but only in large breasted women (Goldilocks technique). An additional 5 patients underwent a total of 8 delayed fat graft only breast reconstructions. One patient underwent immediate reconstruction of one breast and delayed reconstruction of the other. For immediate fat graft reconstructions, volume of fat grafted at the time of the mastectomy averaged 76 ml (range 55-100 ml). The technique has been successfully utilized complete both immediate unilateral and bilateral breast reconstruction in a single stage in select patients and with serial fat grafts in others. However, the comparisons of complication rates between these two methods have not been reported. Methods: A retrospective review of 93 patients (99 breasts) who underwent immediate expander-based breast reconstruction was performed. In partial coverage group, the lateral borders of pectralis major muscles were sutured the mastectomy skin flaps. If the skin flap was too thin be sutured, the serratus anterior muscro-fascial flap was dissected and sutured the lateral border of pectralis major muscle cover the expander completely. Demographics, intraoperative findings, and postoperative complications were compared between two groups. Mastectomy flap necrosis rate was higher in the complete coverage group (Complete 14. Lateral migration rate was higher in the partial coverage group (Complete 0% versus Partial 9. There was no difference in cranial migration rate between two groups (Complete 12. Aichi Cancer Center Hospital, 2 3 Nagoya, Aichi, Japan; Aichi Cancer Center Hospital, Nagoya, Aichi, Japan and Nagoya University, Nagoya, Aichi, Japan. Two hundred fifty four early breast cancer pts underwent immediate artificial breast reconstruction from January 2014 March 2017 in our institution. Good, fair and poor were defined as gained 3 points, 2 points and 0/1 points, respectively. Among 186 pts, the median age was 47 years old (23-75), median body weight was 53kg (35-84), median body mass index was 21. Implant removed in one case because of complications and infection was occurred in five cases. Body: Introduction: the concept of conservative mastectomy with breast reconstruction has led a huge positive impact on the quality of life of breast cancer survivors. Some surgeons use the volume of the mastectomy specimen, believing that the volume of the implant replacing the volume of breast tissue removed is a logical way of thinking. Data on breast weight and volume as well as the size of implants used were prospectively collected. The volume of the breast tissue was assessed by volume displacement method while the weight was measured on a scale in grams. The exclusion criteria included patients with mastectomy specimen weighing more than 2000 grams. Further subgroups were divided into patients younger and those older than 50 years old. Mastectomy volume had a marginally stronger correlation with implant volume/size (N=144, R=0. On the other hand, the weight assessment was more accurate, objective, easier, and more reproducible with minimal inter-observer error. Hence, we believe that the breast weight can be reliably used estimate the size of the implant. Karolinska Institutet, Stockholm, Sweden; Karolinska University Hospital, Stockholm, 3 4 5 Sweden; Karolinska University Hospital, Stockholm, Sweden; Karolinska Institutet, Stockholm, Stockholm, Sweden and Capio St. Breast Center Cologne Holweide, Germany; Klinik fur 3 Senologie Osnabruck, Germany and Unifrauenklinik Koeln, Germany. Also, direct comparisons between titanium-coated polypropylene mesh (TiLoop Bra/TiMesh) and partially absorbable polypropylene mesh (Seragyn) have not yet been reported. Methods: this analysis represents a retrospective single surgeon multi-center study of 320 cases over 14 years (2003 until 2016) using either TiLoop Bra/TiMesh (n=192) or Seragyn (n=128) in breast reconstruction. A significant difference between SurgiMend and Epiflex compared the synthetic meshes could also not been shown. The regimen was 4 cycles of epirubicin (100 or 75 mg/m2), 5-fluorouracil (500 mg/m2), and cyclophosphamide (500 mg/m2) followed by 4 cycles of docetaxel (75 mg/m2). Body: Methods that are eclectic combine whatever seems the best or most useful things from many different areas or systems, rather than following a single system. There are several publications that compare one single technique against another: expander versus flap, pedicled flap versus free flap, etc. Plastic surgeons should dominate several options, fulfill patient expectatives, and high complexity options should be derived high volume centers. The shift combination doxorubicin/cytoxan/taxane from 13% in 1990-98 43% in 1999-2014 was also significant (p <.
Imaging during preoperative systemic aromatase inhibitor (with ovarian suppression for premenopausal therapy should not be done routinely buy albenza 400mg low price treatment nerve damage, but may be considered if tumor women) or tamoxifen purchase 400mg albenza fast delivery treatment xerophthalmia. Imaging prior generic 400mg albenza fast delivery treatment naive definition surgery should be postmenopausal women is an aromatase inhibitor discount 400mg albenza with amex x medications. The use of endocrine therapy and with the commonly used clinicopathologic criteria in selecting patients chemotherapy in these relatively lower risk subsets of women must be for adjuvant chemotherapy in breast cancer with 0 3 positive 317 based on balancing the expected absolute risk reduction and the nodes. For tumors greater than 1 cm in using the risk status based on the 70-gene signature?an absolute 318 diameter chemotherapy is a category 1 recommendation. The panel emphasizes that the recurrence score should marker of relative endocrine resistance independent of type of be used for decision-making only in the context of other elements of risk endocrine therapy. With regards with tamoxifen, chemotherapy, or both showed no significant reduction toxicity, the most important adverse effects noted in all women in the in reduced recurrence or death. Aromatase inhibitors are sequentially by letrozole for 3 years, or letrozole for 2 years followed more commonly associated with musculoskeletal symptoms, sequentially by tamoxifen for 3 years. All three have shown inhibitor for 5 years is better for long-term benefit than 10 years of similar anti-tumor efficacy and toxicity profiles in randomized studies in tamoxifen. The various studies are consistent in amenorrheic with chemotherapy may have continued estrogen demonstrating that the use of a third-generation aromatase inhibitor in production from the ovaries without menses. For those postmenopausal patients with endocrine-responsive, early invasive who remain premenopausal after the initial 5 years of tamoxifen, the breast cancer. A randomized trial evaluated the use of concurrent versus sequential chemotherapy (doxorubicin followed by paclitaxel followed by Other Regimens cyclophosphamide vs. There were 4045 that there are insufficient data make definitive chemotherapy patients included in the joint analysis performed at 3. The panel recommends that treatment should be individualized toxicity was increased in patients treated with trastuzumab. Furthermore, concerns paclitaxel for 4 cycles every 3 weeks or the same regimen with 52 have been raised regarding the long-term cardiac risks associated with weeks of trastuzumab commencing with paclitaxel. Intent-to-treat analysis including a crossover 1010 women were randomized 9 weeks of vinorelbine followed by 3 patient was reported at 4-year median follow-up. An combination) as neoadjuvant chemotherapy can improve outcomes for ongoing study is evaluating pertuzumab and trastuzumab with standard 438,439 women with triple-negative breast cancer. In this study,442 as well as in the cancers that carry a favorable prognosis and often do not require GeparSixto study,441 the addition of carboplatin and/or bevacizumab led systemic therapy is not appropriate. It may be considered as an option in women with high treatment team and includes the performance of regular history/physical lifetime risk (greater than 20% based on models largely dependent on examinations every 4 6 months for the first 5 years after primary family history) of developing a second primary breast cancer. Mammography should be performed contralateral breast cancer after either breast-conserving therapy or annually. Denosumab has shown significantly reduce fractures in Lymphedema is a common complication after treatment for breast postmenopausal women receiving adjuvant therapy aromatase cancer. Factors associated with increased risk of lymphedema include inhibitors, and improves bone mineral density. There is limited evidence (mostly from retrospective studies) on a low-fat eating plan. This ensures accurate determination of metastatic/recurrent disease and tumor histology, and Version 3. The patients experiencing a local recurrence only are supported by analyses discordance rates are in the range of 3. No difference in survival emerged between patients of whether the receptor assay is repeated or the result of the most receiving treatment after initial treatment with mastectomy or recent hormone receptor assay. The panel emphasized the importance use of limited excision of disease with the goal of obtaining clear of individualizing treatment strategies in patients with a recurrence of margins of resection. The data indicate that zoledronic acid and hygiene with periodontal disease and dental abscess. Frequent measurement of calcium, phosphorous, and was 22% when zoledronic acid was administered every 4 weeks versus magnesium may be prudent since hypophosphatemia and 23. Zoledronic acid may be superior pamidronate in lytic breast serum creatinine prior administration of each dose and dose metastasis. There are extensive data from randomized trials in support of the use of Longer durations of bisphosphonate therapy may provide additional bisphosphonates for patients with metastatic disease bone. It is ovarian suppression/ablation plus endocrine therapy as for recommended that patients should undergo a dental examination with postmenopausal women. The optimal duration of treatment breast cancer showed no significant differences in progression-free with denosumab is not known. An improved time progression was seen with fulvestrant compared Combination endocrine therapy in postmenopausal women with anastrazole (median time progression was 23. No differences were every 2 weeks for 3 doses followed by 500 mg monthly versus Version 3. In addition, the recently updated version includes combination with endocrine therapy. Several randomized studies have breast cancer as initial endocrine-based therapy for their metastatic investigated the use of aromatase inhibition in combination with disease. A variety Eribulin is a non-taxane microtubule inhibitor used for the treatment of of chemotherapy regimens are felt be appropriate, as outlined in the patients with metastatic breast cancer who have previously received at treatment algorithm. While a survival advantage was observed with Single agents are categorized as either preferred or other single agents eribulin treatment in all sub-groups of patients, there was a significant based on a balance of the efficacy, toxicity, and treatment schedules of survival advantage observed with eribulin over capecitabine among the drugs. A similar trial enrolled 736 patients who were randomized treatment with docetaxel and bevacizumab or docetaxel Ixabepilone, an epothilone B analogue, is also used for treatment of and placebo. As with endocrine therapy, sequential responses are often observed with chemotherapy, supporting the use of sequential single agents and Combination Regimens combination chemotherapy regimens. Failure achieve a tumor response 3 gemcitabine, carboplatin; and paclitaxel, bevacizumab.
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Patients with low-grade sarcoma should be followed treatment are often appropriate order 400 mg albenza with amex treatment zona. Standard follow-up practice should consist of: ist palliative care services order albenza 400mg mastercard treatment statistics, in coordination with primary care buy generic albenza 400mg online symptoms you have diabetes. Review of any new symptoms reported by the For a number of patients cheap 400mg albenza with mastercard symptoms job disease skin infections, particularly those with poor patient, performance status or signifcant comorbidities, stand b. Clinical examination focus on local recur ard supportive care with symptom control alone, is often rence, with imaging follow-up where indicated the most appropriate option. Early involvement of com by clinical suspicion, munity palliative care teams should be considered in all c. New models of follow-up warrant further investiga The development of optimal treatment protocols is ham tion. The incidence of many of the individual sub-types of soft tis Prognosis and treatment of advanced disease sue sarcoma is too small permit large-scale prospective In almost all cases, the treatment intention for metastatic randomised controlled trials. Approximately 50% of patients with ered from a range of studies which include single-site and high-grade sarcoma develop distant metastases and even multisite phase 2 trials, retrospective case series, sub tually die of disseminated disease, with a median survival analyses of trials for which a range of histological sub of approximately 12 months from diagnosis of metasta types are included and, for the rarer sub-types, individual ses [82?84]. This is likely be endorsed approach palliative treatment depends some extent by the British Sarcoma Group and should therefore be on whether or not symptoms are present, and the poten used alongside this guideline. It is increasingly understood that response rate is defned by absence of disease progression, not degree of only one measure of treatment efcacy with many of the response. A diferential response chemotherapy bination of various strategies, often used in a stepwise according histological subtype has been noted, and as fashion, particularly for those patients with a prolonged knowledge increases it is expected that it will become disease course. The options will take into account the dis increasingly possible individualise treatment. For ease histology, distribution, volume, plus likely sensitiv example; synovial sarcoma, leiomyosarcoma and myxoid ity systemic treatment. Along with systemic treatment, liposarcoma are recognised as having higher response surgery and radiotherapy may be considered target rates chemotherapy. Conversely, alveolar soft part sar symptomatic metastases or in an attempt prolong the coma, extraskeletal myxoid chondrosarcoma and solitary remission period. Other techniques, such as microwave fbrous tumour are generally regarded as insensitive or radiofrequency ablation, may have a role. However, in the era of tar tumour size, or a reduction in tumour volume might geted therapies merely looking at response rates stand facilitate other treatment options. The performance sta ard chemotherapy is starting be superseded by more tus of the patient and comorbidities will play an important specifc relationships between histology and therapeutics. Treatment dose is also a consideration with better understanding of tumourogenesis, and the mecha higher doses shown potentially improve efcacy . In addition, a better understanding Standard second-line treatment is ifosfamide, which is of the immune system has led the development of new also used frst-line where anthracyclines are contraindi agents such as the immune-checkpoint inhibitors which cated, for example in patients at high risk of cardiac com are showing great promise in other tumour types. In difcult perform large enough trials gain the gold unselected sarcomas the response rate is in the region of standard, randomised evidence, that is preferred when 8%, although higher response rates have been observed developing treatment recommendations. It therefore with high-dose (>12 g/m2) and continuous infusion ifos means that, in contrast other cancers, treatment may famide regimens [28, 96, 97]. Ifosfamide is usu develop multicentre clinical trials and recruit patients ally given over two three days as an inpatient, but more into them. Increasingly it is clear that rather than treat recently infusional regimens administering treatment via ing sarcoma as one condition, systemic treatment should a pump over two weeks have been utilised . Treat be tailored the histology or genetics of the individual ment given in this way is usually better tolerated, but so subtype [89?91]. In addition, treatment of advanced disease may involve An alternative second-line option is the combination other modalities such as radiotherapy or surgery, and of gemcitabine and docetaxel. Systemic abine and docetaxel is greatest for uterine leiomyosar treatment should ideally be guided by established proto coma. Tere is potential vari activity in soft tissue leiomyosarcoma and other tumour ability in dosing and administration, particularly in the types including undiferentiated pleomorphic sarcoma use of agents such as ifosfamide, and care should be taken [100, 101]. A recently completed trial in patients into account when discussing the options with patients. The latter combination has not been shown ovial sarcoma, and particularly myxoid liposarcoma, improve survival, although delivers a higher response may also be sensitive. This be aware of rare, but potentially serious rhabdomyolysis, followed subgroup analysis of a study comparing eribu and hepatic toxicity. Local recurrences are often accompanied by metastatic Consideration of previous clinical beneft from chemo disease and patients should be carefully staged for this. Below are a number of should be made regain local control by further surgery options included in the proposed Sarcoma Chemother with adequate margins (wide or radical), and radiother apy Algorithm: apy (if not used previously). It can be combined with ease-free period following primary surgery, absence of ifosfamide. It also has activity in fbromatosis (see other metastases, number of lesions per lung, tumour Desmoid-type fbromatosis section). Paclitaxel: may be used as frst or second line treat the absence of a signifcant disease-free interval, the ment of angiosarcomas . Other approaches can also Of note, activity was also seen in refractory desmo be considered such as radiofrequency or microwave abla plastic small round cell tumour. It how coma, either as a single agent or in combination with ever remains unproven that metasectomy improves long gemcitabine . Management of extrapulmonary oligometastases In most cases extrapulmonary metastases will be It should be noted that not all active agents mentioned treated with systemic treatment. Funding varies across the devolved radiotherapy may be considered for limited metastatic nations and is regularly under review.
The implementation of integrated people centred eye care requires four strategies: 1 buy discount albenza 400 mg line medicine omeprazole. Creating an enabling environment this chapter provides high-level guidance on these four strategies for the eye care sector purchase 400 mg albenza overnight delivery medications medicaid covers. It is acknowledged that countries may have different starting points when implementing these strategies generic albenza 400 mg medications bad for kidneys, depending on the maturity of their health system purchase 400mg albenza symptoms intestinal blockage, resources available, and local needs. Underserved and marginalized populations must be reached in order guarantee universal access quality services that are co-produced according their specifc preferences and needs. In order tailor these requirements address eye care, countries must build targeted policy options and interventions. Health literacy is an essential component of empowering individuals and their families; it is crucial for the effectiveness of many eye care interventions and, more generally, for compliance (2-4). The vast majority of cases of vision impairment caused by common eye conditions, such as diabetic retinopathy and glaucoma, are avoidable with early detection and timely intervention (5-7). However, a large proportion of individuals remain undiagnosed because these conditions are often asymptomatic in their early stages; awareness of the importance of regular eye examinations among high-risk the eye care sector populations (such as the elderly and those with diabetes) is largely needs increase lacking. In some situations, inadequate knowledge of the availability of its efforts services, along with a tendency for individuals consider reduced provide sound, vision as part of the normal ageing process, can also lead poor and effective outcomes (8). Furthermore, even when individuals are aware having an eye condition, poor eye health literacy can limit adherence education. The eye care sector needs increase its efforts provide sound, and effective education. Strategies for engagement and empowerment can occur at the individual or specifc population group level. One of the examples of effective community empowerment in the feld of eye care is the community-directed treatment with ivermectin as a preventive intervention for onchocerciasis (Box 6. Ivermectin is an effective and safe medicine for the mass treatment of onchocerciasis. Mobile teams of health workers faced a range of challenges with initial methods of ivermectin distribution including low coverage, minimal community involvement, and high costs the health system. This strategy has resulted in substantial achievements for onchocerciasis control in Africa: Over 142 million people received treatment for onchocerciasis by the end of 2017. In the same year, fourteen countries reported having achieved 100% geographical coverage. Eye care literacy must target raising awareness of the availability of Outreach eye care vision rehabilitation. Many individuals with severe vision impairment services have been and blindness that cannot be treated may live in situations of shown effective in dependency because they or, their family and community, are unaware increasing service that rehabilitation services can be provided achieve independence. If coverage in hard these services are unavailable, health literacy can engage people to-reach advocate for them. For example, routine mobile text messages have been shown increase the rate of attendance at eye care facilities (12). The use of electronic health records, and ensuring that patients have easy access their records, are additional ways of strengthening communication between eye care patients and providers (13-15). Outreach eye care services have been shown effective in increasing service coverage in hard-to-reach communities, enabling greater responsiveness local community needs (16, 17). When implementing eye care programmes, it is important ensure that they are an integral part of the health sector service delivery system, both for sustainability and because new avenues of delivery of eye care interventions can then be explored. For example, eye care interventions, such as screening, can 119 be integrated into the delivery systems of existing health interventions, such as for vaccines. To simplify access care for underserved populations, rapid technological change also has potential. As described in Chapter 4, telehealth is employed effectively in the feld of eye care. Telehealth supports people in rural and remote settings who are otherwise underserved (18, 19), and facilitates care coordination between care providers (Box 6. To simplify access care for underserved populations, rapid technological change has potential. Ophthalmology is particularly suited telemedicine due its high reliance on imaging for the diagnosis and management of ocular disease. Referrals the service originate from optometrists working within regional communities, with rural hospital emergency departments and general practitioners often referring patients for optometric review. The service provides a combination of store-and-forward and real-time telemedicine links, with results of ophthalmic investigations being sent the treating ophthalmologist prior a real-time video consultation. Following advocacy and a demonstrated evidence base, government health insurance rebates were introduced for optometrists and general practitioners support telehealth in 2015. There are minimal additional infrastructure costs, given that ubiquitous platforms such as Skype or FaceTime are used for video-consultations. The provision of both an online booking system and availability for on call urgent assessment reduces barriers for uptake. The provision of video consultations that include patient consent, and booking, for surgery has resulted in several key outcomes. Firstly, it has eliminated the wait for the waiting list, where patients can wait for up one year for a public service outpatient appointment prior being placed on the waiting list for surgery. In situations where more specialized services are required for example after the detection of cataracts or diabetic retinopathy primary care can facilitate referrals and coordination across providers and care settings. Given that many of the eye conditions that can be effectively managed at the primary care level are often conditions for which people seek eye care in secondary and 122 tertiary eye care settings (22-26), building both a strong primary care and a community delivered eye care can increase the effciency of eye care services. Of note, building eye care that is integrated into primary care does not place any less importance on secondary and tertiary levels. There is no single path countries can follow achieve a strong primary care that includes eye care. Until recently this curriculum did not include eye and ear care and, as a result, these services were not provided at the primary care level throughout the country.
Massive vaginal bleeding (in women of childbearing age) and gastrointestinal bleeding may occur during this phase but is not common (5) albenza 400 mg overnight delivery my medicine. The earliest abnormality in the full blood count is a progressive decrease in total white cell count buy cheap albenza 400mg on-line symptoms 2 weeks pregnant, which should alert the physician 400mg albenza 9 medications that can cause heartburn a high probability of dengue order 400 mg albenza amex symptoms 6 dpo. Progressive leukopenia (3) followed by a rapid decrease in platelet count usually precedes plasma leakage. At this point patients without an increase in capillary permeability will improve, while those with increased capillary permeability may become worse as a result of lost plasma volume. Pleural effusion and ascites may be clinically detectable depending on the degree of plasma leakage and the volume of fuid therapy. The degree of increase above the baseline haematocrit often refects the severity of plasma leakage. With prolonged shock, the consequent organ hypoperfusion results in progressive organ impairment, metabolic acidosis and disseminated intravascular coagulation. This in turn leads severe haemorrhage causing the haematocrit decrease in severe shock. Instead of the leukopenia usually seen during this phase of dengue, the total white cell count may increase in patients with severe bleeding. In addition, severe organ impairment such as severe hepatitis, encephalitis or myocarditis and/or severe bleeding may also develop without obvious plasma leakage or shock (8). Some 26 patients progress the critical phase of plasma leakage without defervescence and, in Chapter 2: Clinical management and delivery of clinical services these patients, changes in the full blood count should be used guide the onset of the critical phase and plasma leakage. Cases of dengue with warning signs will probably recover with early intravenous rehydration. General well-being improves, appetite returns, gastrointestinal symptoms abate, haemodynamic status stabilizes and diuresis ensues. The haematocrit stabilizes or may be lower due the dilutional effect of reabsorbed fuid. White blood cell count usually starts rise soon after defervescence but the recovery of platelet count is typically later than that of white blood cell count. Respiratory distress from massive pleural effusion and ascites will occur at any time if excessive intravenous fuids have been administered. During the critical and/or recovery phases, excessive fuid therapy is associated with pulmonary oedema or congestive heart failure. The various clinical problems during the different phases of dengue can be summarized as in Table 2. As dengue vascular permeability progresses, hypovolaemia worsens and results in shock. It usually takes place around defervescence, usually on day 4 or 5 (range days 3?7) of illness, preceded by the warning signs. During the initial stage of shock, the compensatory mechanism which maintains a normal systolic blood pressure also produces tachycardia and peripheral vasoconstriction with reduced skin perfusion, 27 Dengue: Guidelines for diagnosis, treatment, prevention and control resulting in cold extremities and delayed capillary refll time. Uniquely, the diastolic pressure rises towards the systolic pressure and the pulse pressure narrows as the peripheral vascular resistance increases. The inexperienced physician may measure a normal systolic pressure and misjudge the critical state of the patient. Prolonged hypotensive shock and hypoxia may lead multi-organ failure and an extremely diffcult clinical course (Textbox D). Hypotension is usually associated with prolonged shock which is often complicated by major bleeding. Patients with severe dengue may have coagulation abnormalities, but these are usually not suffcient cause major bleeding. When major bleeding does occur, it is almost always associated with profound shock since this, in combination with thrombocytopaenia, hypoxia and acidosis, can lead multiple organ failure and advanced disseminated intravascular coagulation. Massive bleeding may occur without prolonged shock in instances when acetylsalicylic acid (aspirin), ibuprofen or corticosteroids have been taken. Unusual manifestations, including acute liver failure and encephalopathy, may be present, even in the absence of severe plasma leakage or shock. However, most deaths from dengue occur in patients with profound shock, particularly if the situation is complicated by fuid overload. Severe dengue should be considered if the patient is from an area of dengue risk presenting with fever of 2?7 days plus any of the following features. There is evidence of plasma leakage, such as: high or progressively rising haematocrit; pleural effusions or ascites; circulatory compromise or shock (tachycardia, cold and clammy extremities, capillary refll time greater than three seconds, weak or undetectable pulse, narrow pulse pressure or, in late shock, unrecordable blood pressure). The key component of the process is the delivery of good clinical services at all levels of health care, from primary tertiary levels. Most dengue patients recover without requiring hospital admission while some may progress severe disease. Simple but effective triage principles and management decisions applied at the primary and secondary care levels, where patients are frst seen and evaluated, can help in identifying those at risk of developing severe disease and needing hospital care. This should be complemented by prompt and appropriate management of severe dengue in referral centres. Activities at the frst level of care should focus on: recognizing that the febrile patient could have dengue; notifying early the public health authorities that the patient is a suspected case of dengue; managing patients in the early febrile phase of dengue; recognizing the early stage of plasma leakage or critical phase and initiating fuid therapy; recognizing patients with warning signs who need be referred for admission and/or intravenous fuid therapy a secondary health care facility; recognizingandmanagingsevereplasmaleakageandshock,severebleeding and severe organ impairment promptly and adequately. Primary and secondary health care centres At primary and secondary levels, health care facilities are responsible for emergency/ ambulatory triage assessment and treatment. Triage is the process of rapidly screening patients soon after their arrival in the hospital or health facility in order identify those with severe dengue (who require immediate emergency treatment avert death), those with warning signs (who should be given priority while waiting in the queue so that they can be assessed and treated without delay), and non-urgent cases (who have neither severe dengue nor warning signs). During the early febrile phase, it is often not possible predict clinically whether a patient with dengue will progress severe disease. Various forms of severe manifestations may unfold only as the disease progresses through the critical phase, but the warning signs are good indicators of a higher risk of developing severe dengue.