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By B. Basir. Bienville University. 2019.

Each ambulance station would have two rooms of 15’x15’ dimensions with attached bathroom buy discount malegra dxt 130mg on line. Each Station will have one ambulances to provide uninterrupted services on 24x7 basis malegra dxt 130mg sale. The life support ambulances would be made available to identified hospitals for inter hospital transfer buy malegra dxt 130mg cheap. The speciality of Emergency Medicine is distinct and comprises of more than caring for ‘war casualties’ as the name was originally intended to be purchase 130mg malegra dxt with mastercard. Therefore, the department needs to be conducive to prompt and efficient patient care. It is important to realise that this does not end with establishing four walls and facilities but involves planning, organising, staffing, training and quality control. Even though District Hospitals have functional Emergency Rooms, many such areas do not provide standard emergency care due to lack of planning, trained staff and equipments. Therefore, it is of utmost importance that emergency services in the District Hospitals be upgraded, for better outcome. Emergency Services: The emergency department would provide well-organized medical, paediatric, (including neonatal) surgical, obstetric, trauma care and anaesthetic services. Physical facilities: Physical facilities should include reception, triage area, treatment area, operating theatres, labour and delivery room, high dependency area, blood bank, laboratory, diagnostic imaging, sterilization, water, electricity, safe waste disposal and communications. The district hospitals would be upgraded to the required level and equipped adequately. Equipment and instrument: The District hospital would be equipped with surgical instruments for minor surgery, major surgery, obstetrics and gynaecology surgery, orthopaedic surgery, anaesthetic equipment, resuscitation equipment and monitoring equipment. Supplies system:There would be uninterrupted supply of essential drugs, blood and intravenous fluids and other consumables e. Personnel: Clinical personnel with appropriate qualification and training in emergency medicine, general surgery, orthopaedics and traumatology, obstetrics and gynaecology; anaesthesia and resuscitation should be available along with adequate number of nurses and support staff. Evaluation of training needs and coordinated plan for continuing medical education, especially for enhancing skills, should be an ongoing programme. The practice of emergency care is team work and all personnel need to work together to achieve expected standards of emergency care. Quality Assurance: A quality assurance system to improve the quality and equity of patient care needs to be in place. Protocol Manuals are available and an indigenously developed one is most suitable and practical. Moreover it is prudent to implement treatment protocols in concurrence with the various departments of the hospital. Proper digital record management and clinical audit also assures quality service in hospital systems. Triage Triage is the process of getting the right patient to the right place at the right time with the right care provider. In disaster settings where there are multiple emergencies, effort would be to provide the most effective care for the greatest number of patients. In non disaster settings, the efforts of emergency department would be to provide the best care for each individual patient. The guiding principles would be to identify patients requiring immediate care, determine the appropriate area for treatment and facilitate patient flow through the emergency and avoid unnecessary congestion. A 3 stage uniform coding would be followed for patients requiring immediate care, those requiring monitoring for worsening of conditions and those ‐ 200 ‐ who could be managed in out- patient departments. It would be realized through satellite based, terrestrial band-width based and truncated radio system. It provides for receiving call, dispatch of the ambulance, communication to and fro from ambulance and hospital, tele/video conferencing, ambulance tracking and data management. The proposed system must have an open architecture and be based on Web Browser technology, capable of scaling up. The configurations should provide for enabling telemedicine operations within the network and identified centre. The control room would house servers, switches, backup power system, dispatch etc and work stations for the call taker, call dispatcher and supervisor. The windows/browser based software interface would allow the attending officer to record the name and other details. The system would be able to send visuals of the patient (extend of trauma) and the procedures being done with in the cabin through a camera to the central control room and the specialist station and get real time feed back to the ambulance. Data Terminal-Hospital The data terminal within the hospital would reside in the communication control room. It would provide three way communication with ambulance / the ambulance station, the central control centre and higher referral centre. The specifications are such that it can be scaled up for the future to address the need of a fleet of 15000 ambulances operating through multiple control rooms. This could be taken from any service provider who should ensure dedicated connectivity. Toll Free Number The telecommunication department would provide with a nation-wide applicable 3 digit call number which would replace the existing multitude of 3 digit/ four digit numbers. Towards the end of the plan period the Instituional frame work of National authority and the State councils would take shape. Deluxe extremity vacuum splint Kit Model: D-S1749, Set Contents: (a) 2 Splints(leg, arm and 01 No. Patient Cabin: Fibre cup-boards to fix ventilator / monitor / defibrillator / and suction 01 No. Patient Cabin: Medicine rack, 3 drawers with containers for keeping bandage, gauzes 01 No.. Patient Cabin: Medicine rack, 4 drawers with containers for keeping medicine, 01 No. Patient Cabin: Anti skit and shock absorbing mat for keeping medical equipments like 01 No. Patient Cabin: Patient attender seat (3 seater) with safety belt and cup-board ‐ 204 ‐ 23. Blue and Red Siren Lights, 100W Siren amplifier, Public Address System, 100w Siren 01 No. Resuscitation Areawhere patients who have had a cardiac arrest, patients in shock or poly-trauma patients can be resuscitated. This room should be of an adequate size so that at least two patients can be simultaneously resuscitated. It should have the required resuscitation drugs and equipment, a defibrillator with external pacer, cardiac monitor and pulse oximeter. Central nursing station - where all the patients can be easily monitored by the medical and nursing staff. There should be cabinets where commonly used medications, syringes, needles, intravenous cannulae and sets are kept. Facilities for application of splints and Plaster of Paris casts should also be available. Sterile procedure room where minor surgery and sterile procedures under conscious sedation can be performed. Operating Theatres-Should have an operating theatre to perform minor and major procedures. Labour and delivery wardand Neonatal management facility: The District hospital should have facilities or normal delivery and complications arising due to pregnancy and to safeguard the health of new born. High dependency area: About 10 beds should be high dependency beds to manage all critical patients. Support Services _ Continuous oxygen supply _ Blood bank and laboratory _ Diagnostic imaging Autoclave and other means of sterilization _ Safe waste disposal _ Water, electricity and communications. Several sets of duplicate instruments may be needed to allow continuous provision of services during sterilization. However, in clinical practice that would be unsuitable since an unstable patient, waiting for his turn in the queue is bound to deteriorate significantly if there is delay in medical attention. The philosophy of triage is to ensure that ‘the sickest is seen first’ and is based on quick evaluation of the patient. Triage in the Emergency Department Triage includes focused physical examination appropriate to the organ system, referred to in the chief complaint. For example, patients who have complained of earache must have an examination of the ear. Triage should be routine daily operation and all patients presenting to an Emergency Department should be triaged on arrival by a specifically trained and experienced registered nurse. Triage for India Although many systems exist, a simple 3-tier system is recommended. It is in practice in India since 1997 and has been found to be efficient and practical. Category I (obvious life-threatening emergency): The physician must examine the patient with zero delay. Case examples include cardiac arrest, continuous seizures, acute severe chest pain, haematemesis, sudden loss of consciousness, major trauma with hypotension, etc. Although some of these patients initially may appear to have not-so-serious chief complaints, about 25% of these patients have high-risk conditions. The patient needs full evaluation and treatment by a physician within 10 minutes of arrival, since there could be potential instability to the vital observations. Case examples include dyspnoea, high fever, acute abdominal pain, acute confusion, severe pain, serious extremity injuries, large lacerations, etc. Case examples include chronic, minor, or self-limiting disorders, medication refill, skin disorders, mild adult upper respiratory tract symptoms, mild sore throat, blood pressure check, etc. High respiratory rates are one of the most sensitive indicators of severely ill or injured patients. The person performing triage should not judge whether the person might be exaggerating his or her pain. Selection of the candidates for admission to the course will be made on merit, on all India basis in government hospitals 4. Medium of Teaching: English Staffing Full time teaching Faculty in the ratio of 1:6 Minimum faculty: Five faculty by name should be available for the course. Chief Co-ordinator: Emergency physician /Anesthesiologist/ Gen Surgeon/Gen Physician Coordinators : Orthopedics surgeon, Emergency physician/ Physician/ cardiologist etc Roles of All Faculty should be defined clearly. Course objectives: At the end of the course the student will be able to • Describe the concepts and principals of Emergency Medical Care • Perform basic and advanced life/limb saving skill in pre-hospital & hospital setting • Apply clinical knowledge and practical skills to real life scenarios. Budget: There should be budgetary provision for Audiovisual aids, stationary, Library, secretarial help, contingency expenses etc Physical facility 1. Library- permission to use institute library having current text books, internet, trauma journal, Emergency medicine journals etc. Semester System with 20% of total grade as per grading system in internal assessment 3. Assessment should be as grading and report, not marks with written detail report on all the objectives of examination. Knowledge :Assess the knowledge of basic concepts, theory, and principles of Emergency medical care 2.

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The main features may be subdivided into (1) the epidermal thickening discount malegra dxt 130 mg with amex, (2) the inflam- matory component order malegra dxt 130 mg with visa, and (3) the vascular component cheap malegra dxt 130mg free shipping, but of course all are closely interlinked discount malegra dxt 130mg on line. The epidermal thickening The epidermis shows marked exaggeration of the rete pattern and elongation of the epidermal downgrowths with bulbous, club-like enlargement of their ends (Fig. The average thickness is increased from about three to four cells in the normal skin to approximately 12–15 cells in the psoriatic lesion. Many mitotic fig- ures can be seen and the rate of epidermal cell production seems to be greatly enhanced. The turnover time of psoriatic epidermis and stratum corneum is con- sequently very much shortened. Normally, it takes some 28 days for new cells to ascend from the basal layer and travel through the epidermis and the stratum corneum and reach the surface. Epidermal nuclei are retained in the inefficient horny layer that results (parakeratosis). The inflammatory component Interspersed between the ‘parakeratotic’ horn cells are collections of desiccated polymorphonuclear leucocytes known as Munro microabscesses. The dermis immedi- ately below the epidermis also contains many inflammatory cells, mostly lym- phocytes. In pustular psoriasis, the epidermal component is much less in evidence and there are collections of inflammatory cells within the epidermis (Fig. The vascular component The papillary capillaries are greatly dilated and tortuous to a degree not seen in other inflammatory skin disorders. Ultrastructurally it can be seen that there are larger gaps than usual between the endothelial cells. One very obvious abnormality in psoriasis is the hyperplastic epidermis with increased mitotic activity, and one line of intense investigation was directed at the control of epidermal cell production in this disease. Attention has moved away from this possibility in recent years and focused more on the 137 Psoriasis and lichen planus inflammation and possible immunopathogenesis. The disorder often responds to immunosuppressive agents such as cyclosporin and methotrexate and currently psoriasis is thought of as a ‘lymphocyte-driven’ disease. Various potentially heritable biochemical abnormalities have been suggested and/or described that could explain both the increased epidermal proliferation and the inflammatory component. At different times, alterations in the skin content or activity of cyclic nucleotides, polyamines, eicosanoids, cytokines and growth fac- tors have been described, but in most cases these changes are secondary to the underlying and fundamental less well-characterized events. Infection has been considered as a cause and in recent years the involvement of retroviruses has been suggested. Case 8 Jessie’s mother and aunt had psoriasis and at the age of 19 Jessie thought that she was getting it too, as she had scaling patches on her knees and elbows and in her scalp. She also noticed some separation of the nail plates from the nail beds and pitting of three of her fingernails. The rash disappeared after 6 weeks, but unfortunately recurred the following year. In other patients, simple treatment with an emollient such as white soft paraffin, by itself or with 2 per cent salicylic acid, is sufficient when used once or twice daily. Tar-containing preparations are less popular than previously, but may suit some patients who can put up with the stinging, the unpleasant smell and the staining. Tar has anti-inflammatory and cytostatic activity and certainly has mild anti-psoriatic effect. Proprietary tar preparations have some advantages over the British National Formulary formulations. Used alongside medium-potency corticosteroids, the efficacy is increased and the skin imitation decreased. A preparation of calcipotriol formulated together with betamethasone-17-valerate is now available as ‘Dovobet’, and does appear quite effective. Tacalcitol is another vitamin D3 analogue, which, although effective when employed topically, is not as potent as calcipotriol. Apart from skin irrita- tion, there is the concern that sufficient of these D3 analogues will be absorbed to cause hypercalcaemia. To make dithranol treatment suitable for out-patients, the tendency has been to use either dithranol in white soft paraffin or one of the proprietary preparations such as Dithrocream®, which is available in different strengths. Dithranol often irritates and burns the skin and care must be taken to match the concentration used to the individual patient’s tolerance. It also causes a distinctive brown-purple staining of clothes, towels and skin (Fig. They are useful for patients with flexural lesions for which other irritant preparations are not suitable. For the same reason, weak topical corticosteroids are also suitable for lesions on the genitalia and the face. Potent topical corticosteroids should not be used, because frequent use is likely to lead to side effects (see page 307) and because eventual withdrawal may lead to severe rebound and even the appearance of pustular lesions. Potent topical steroids (such as fluocinolone acetonide or betamethasone dipropionate) may be suitable for use on the scalp and their use is sometimes justifiable on the palms and soles if other treatment is not helping. When used alongside medium-potency topical corti- purple staining on the skin costeroids, its efficiency is increased and the irritation experienced by some due to dithranol. Both the vitamin D3 analogues and tazarotene may improve psoriasis by modulating gene activity and redirecting differentiation and by reducing the epidermal proliferation. When more than 15 per cent of the body surface area is involved, topical treatment becomes very difficult. It is thought that this antiproliferative activity may be important in reducing epidermal and lympho- cyte proliferation. Whichever way it works, it is a highly effective treatment for patients with severe psoriasis. Unfortunately, it is also quite toxic, producing hepa- totoxicity in most patients who stay on the drug for long periods. To minim- ize the possibility of serious side effects, patients must be monitored frequently (preferably monthly) by blood counts and blood biochemistry. It is recommended that a liver biopsy is performed both before treatment begins and after a cumul- ated dose of 1. It is mainly suitable for those who would otherwise be disabled by the disease, and for some elderly patients with severe psoriasis. The retinoids Retinoids are analogues of retinol (vitamin A) and have been found to exert important actions on cell division and maturation. The drug benefits patients with all types of severe psoriasis after 3–4 weeks, but is of most help when used in combin- ation with ultraviolet treatment. Its major drawback is that it is teratogenic and can only be given to fertile women if they use contraception and are prepared to continue using the contraceptive measures for 3 years after stopping treatment. Other significant toxicities include hyperlipidaemia and a possibility of hyper- ostosis and extraosseous calcification. These ‘significant’ toxicities are not common, but minor mucosal side effects occur in all patients, including drying of the lips and the buccal, nasal and conjunctival mucosae. Cyclosporin Cyclosporin is an immunosuppressive agent used in organ transplantation. Its place in the treatment of disabling and severe psoriasis is assured, but great care and constant monitoring are required. The main psoralen used is 8-methoxy psoralen, but 5-methoxy psoralen and trimethoxy psoralen are sometimes used. The dose required for clearance is approximately 50–100 J/cm2 and care is taken to keep the dose as low as possible and certainly below a total cumulated dose of 1500 J/cm2 to reduce the possibility of long-term side effects. In the short term, nausea is often experienced and, if too long an exposure is given, burning can occur. These range from propylthiouracil to fumaric acid derivatives and new immunosup- pressive agents such as tacrolimus. Usually, the disease begins on the face and scalp, with pinkness and scaling, and spreads within a few days or a week or two to involve the rest of the body. There is a characteristic orange hue to the redness, and on the thickened palms there is a characteristic yellowish discoloration (Fig. Scattered amongst the red, scaling eruptions are islands of spared 142 Pityriasis rubra pilaris Figure 9. There is also an infantile type which, although similar in many ways to the adult form, tends to be much more stubborn and resistant to treatment. The histological appearance is distinctive in that, although there is considerable epidermal thickening, the accentuation of the dermal papillae and the undula- tions of the dermoepidermal junction are much less marked than in psoriasis. It is characterized by an eruption of variable extent of typical mauve or pink, flat-topped, itchy papules. The papules are often aggregated in some sites, for example the front of the wrist (Fig. Usually, only a few lesions develop, but in some cases the eruption may be dense and generalized. The mucosae are often affected and lesions occur in the mouth in some 30 per cent of patients. A white lacework pattern on the buccal mucosa is the most frequently observed type of lesion (Fig. Less com- monly, a destructive process develops in which the nail plate is lost and the nail- forming tissue (the nail matrix) is damaged. The scalp is sometimes affected and then localized patches of hair loss and scalp scarring occur. As lesions heal, they flatten and often leave a pigmented patch, which persists for some weeks. The commonest variant is hypertrophic lichen planus, in which thickened, mauv- ish papules or nodules of irregular shape with a warty or scaling surface develop (Fig. Solitary hypertrophic lesions may appear in the course of ordinary lichen planus or develop as solitary lesions. This odd variant sometimes occurs on the male genitalia and lower abdomen, but rarely elsewhere. Lichen nitidus is a rare variant of lichen planus in which numerous tiny, pink, flat-topped papules develop. Bullous lichen planus is a very rare variant in which blistering occurs on some lesions. Affected sites lose their terminal hair and develop horny spines, which project from the affected hair follicles. Amongst the inflammatory cell infiltrate are clumps of melanin pigment as a result of damage to the epidermis. Immunofluorescence studies show a dense, ragged band of fibrin at the dermo- epidermal junction and clumps of IgM deposit. The basic process is thought of as an immunological attack on the basal layer; the presence of inflammatory cells and the other epidermal alterations are believed to be secondary events.

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The natural history of viral infections of host rodents has not been characterized generic malegra dxt 130mg amex. Indoor exposure in closed buy 130mg malegra dxt, poorly ventilated homes malegra dxt 130 mg low cost, vehi- cles and outbuildings with visible rodent infestation is especially impor- tant best 130 mg malegra dxt. Incubation period—Incompletely defined but thought to be ap- proximately 2 weeks with a range of a few days to 6 weeks. Period of communicability—Person-to-person spread of hantavi- ruses has been reported during an outbreak in Argentina. Susceptibility—All persons without prior infection are presumed to be susceptible. No inapparent infections have been documented to date, but milder infections without frank pulmonary oedema have oc- curred. No second cases have been identified, but the protection and duration of immunity conferred by previous infection is unknown. Control of patient, contacts and the immediate environment: 1), 2), 3), 4), 5) and 6) Report to local health authority, Isola- tion, Concurrent disinfection, Quarantine, Immunization of contacts and Investigation of contacts and source of infec- tion–See section I, 9B1 through 9B6. Cardiotonic drugs and pressors given early under careful monitoring help prevent shock. Epidemic measures: Public education regarding rodent avoid- ance and rodent control in homes is desirable in endemic situations and should be intensified during epidemics. Monitor- ing of rodent numbers and infection rates is desirable but as yet of unproven value. Identification—These are newly recognized zoonotic viral dis- eases named for the locations in Australia and Malaysia where the first human isolates were confirmed in 1994 and 1999, respectively. Nipah virus manifests mainly as encephalitis; Hendra virus as a respiratory illness (2 cases) and as a prolonged and initially mild meningoencephalitis (1 case). The full course and spectrum of these diseases is still unknown; symptoms range in severity from mild to coma and death and include fever and headaches, sore throat, dizziness, drowsiness and disorientation. The case-fatality rate for clinical cases is about 50%; subclinical infections occur. Infectious agent—Hendra (formerly called equine morbillivirus) and Nipah viruses are members of a new genus, Henipaviruses,ofthe Paramyxoviridae family. In 1994, 3 human cases followed close contact with sick horses, the first 2 during the initial outbreak in Hendra, the 3rd occurring 13 months after an initially mild meningitic illness when the virus reactivated to cause a fatal encephalitis. Nipah virus affected swine in the pig-farming provinces of Perak, Negeri Sembilan, and Selangor in Malaysia. The first human case is believed to have occurred in 1996; although the disease became apparent in late 1998, most cases were identified in the first months of 1999, with over 100 confirmed deaths as of mid-1999. During 1999 11 abattoir workers in Singapore developed Nipah virus infection following contact with pigs imported from Malaysia. Reservoir—Fruit bats for Hendra virus; virus isolation and serolog- ical data suggest that Nipah virus may have a similar reservoir. Dogs infected with Nipah virus show a distemper-like manifestation but their epidemiological role has not been defined. Nipah-seropositive horses have been identified, but their role is also undetermined. Testing of other animals is under way; susceptibility testing suggests that cats and guineapigs can be infected, sometimes with fatal outcomes, mice, rabbits and rats appear refractory to infection. Mode of transmission—Primarily through direct contact with infected horses (Hendra) or swine (Nipah) or contaminated tissues. Preventive measures: Health education about measures to be taken and the need to avoid fruit bats. Report to local authority: Case report should be obligatory wherever these diseases occur; Class 2 (see Reporting). Isolation: Of infected horses or swine; no evidence for person-to-person transmission. Concurrent disinfection: Slaughter of infected horses or swine with burial or incineration of carcases under govern- ment supervision. Quarantine: Restrict movement of horses or pigs from infected farms to other areas. Specific treatment: None at present, although there is some research evidence that ribavirin may decrease mortality from Nipah virus. Precautions by animal handlers: protective clothing, boots, gloves, gowns, goggles and face shields; washing of hands and body parts with soap before leaving pig farms. Slaughter of infected horses or swine with burial or incin- eration of carcases under government supervision. International measures: Prohibit exportation of horses or pigs and horse/pig products from infected areas. Identification—In most of the industrialized countries, infection occurs in childhood asymptomatically or with a mild illness. The latter infections may be detectable only through laboratory tests of liver function. Onset of illness in adults in nonendemic areas is usually abrupt with fever, malaise, anorexia, nausea and abdominal discomfort, followed within a few days by jaundice. The disease varies in clinical severity from a mild illness lasting 1–2 weeks to a severely disabling disease lasting several months. Prolonged, relapsing hepatitis for up to 1 year occurs in 15% of cases; no chronic infection is known to occur. In general, severity increases with age, but complete recovery without sequelae or recurrences is the rule. If laboratory tests are not available, epidemiological evidence may provide support for the diagnosis. Occurrence—Worldwide, geographic areas can be characterized by high, intermediate, or low levels of endemicity. Levels of endemicity are related to hygienic and sanitary conditions of geographic areas. Improved sanitation in many parts of the world is leaving many young adults susceptible and the frequency of outbreaks is increas- ing. Where environmental sanitation is poor, infection is common and occurs at an early age. Epidemics often evolve slowly in industrialized countries, cover wide geographic areas and last many months; common source epidemics may evolve rapidly. During some outbreaks, day care center employees or attenders, men with multiple male sex partners and injecting drug users may be at higher risk than the general population. In recent years, community-wide outbreaks have accounted for most disease transmission, although com- mon source outbreaks due to food contaminated by food handlers and contaminated produce continue to occur and require intensive public health efforts to control. Outbreaks have been reported among susceptible persons working with nonhuman primates raised in the wild. Common source outbreaks have been related to contaminated water; food contaminated by infected food handlers, including foods not cooked or handled after cooking; raw or undercooked molluscs harvested from contaminated waters; and contaminated produce such as lettuce and strawberries. Transmission through transfusion of blood and clotting factor concentrates obtained from viraemic donors during incubation has been reported, albeit rarely. Period of communicability—Studies of transmission in humans and epidemiological evidence indicate that maximum infectivity occurs during the latter half of incubation and continues for a few days after onset of jaundice (or during peak aminotransferase activity in anicteric cases). Low incidence of manifest disease in infants and preschool children suggests that mild and anicteric infections are common. Preventive measures: 1) Educate the public about good sanitation and personal hygiene, with special emphasis on careful handwashing and sanitary disposal of feces. The dose of vaccine, vaccination schedule, ages for which the vaccine is licensed, and whether there is a pediatric and adult formulation all vary from manufacturer to manufacturer, and they are not licensed for use in children under 1. Protection against clinical hepatitis A may begin in some persons as soon as 14–21 days after a single dose of vaccine, and nearly all have protective levels of antibody by 30 days after receiving the first dose of vaccine. In industrialized countries with low endemicity and with high rates of disease in specific high-risk populations, vaccination of these populations against hepa- titis A may be recommended. Recommendations for hepatitis A vaccination in out- break situations depend on the epidemiology of hepatitis A in the community and the feasibility of rapidly implementing a widespread vaccination program. The use of hepatitis A vaccine to control community-wide outbreaks has been most successful in small self-contained communities when vacci- nation is started early in the course of the outbreak and with high coverage of multiple-age cohorts. Management of day care centers should stress measures to minimize the possibility of fecal-oral transmis- sion, including thorough handwashing after every diaper change and before eating. The same should be considered for family contacts of children in diapers attending centers where outbreaks occur and cases are recognized in 3 or more families. In endemic areas, travellers should take only hot or bottled beverages and hot, well-cooked food. Epidemic measures: 1) Determine mode of transmission (person-to-person or com- mon vehicle) through epidemiological investigation; identify the population exposed. Specific outbreak control measures must be tailored to the characteristics of hepatitis A epide- miology and of the existing hepatitis A immunization pro- gram, if any, in the community. Immunization of older children who have not previously received vaccine should be accelerated in communities with ongoing programs of rou- tine hepatitis A immunization for young children; target immunization should be undertaken for groups or areas (age groups, risk groups, census tracts) where local surveillance and epidemiological data show the highest rates. In outbreak settings such as day care, hospitals, institutions and schools, routine use of hepatitis A vaccine is not warranted. These immunization programs may reduce disease incidence only in the group(s) targeted. Disaster implications: Hepatitis A is a potential problem in large collections of people with overcrowding, inadequate san- itation and water supplies; if cases occur, increased efforts should be exerted to improve sanitation and safety of water supplies. Mass administration of hepatitis A vaccine, which should be carefully planned, is not a substitute for environmental measures. In those with clinical illness, the onset is usually insidious, with anorexia, vague abdominal discomfort, nausea and vomiting, some- times arthralgias and rash, often progressing to jaundice. Severity ranges from inapparent cases detectable only by liver function tests to fulminating, fatal cases of acute hepatic necrosis. Persons with chronic infection may or may not have a history of clinical hepatitis. About one-third have elevated amino- transferases; biopsy findings range from normal to chronic active hepatitis, with or without cirrhosis. HbsAg is present in serum during acute infections and persists in chronic infections. Most of these infections would be prevented by perinatal vaccination against hepatitis B of all newborns or infants. Serological evidence of previous infection may vary depending on age and socioeconomic class. Contaminated and inadequately sterilized syringes and needles have resulted in outbreaks of hepatitis B among patients; this has been a major mode of transmission worldwide. Chimpanzees are susceptible, but an animal reservoir in nature has not been recognized. Closely related hepadnavi- ruses are found in woodchucks, ducks, ground squirrels and other animals such as snow leopards and German herons; none cause disease in humans. Sexual transmission from infected men to women is about 3 times more efficient than that from infected women to men. Anal intercourse, insertive or receptive, is associated with an increased risk of infection.

For possible loosening buy discount malegra dxt 130mg, with or without infection purchase 130mg malegra dxt fast delivery, but The recent adaptations suggest that periprosthetic soft tis- radiographs normal: joint aspiration with or without an sues may be visualized better [10] buy 130mg malegra dxt otc. Other complications that may be demonstrated include The radiographs suggest loosening malegra dxt 130 mg line, but is the joint in- hematomata, fat-pad scarring and heterotopic bone forma- fected also? These criteria are currently being tensity and contrast enhancement decrease while the fat and reevaluated. In patients in whom re- current dislocation is a problem, the absence of the posteri- Small-Particle Disease or capsule and disruption of external rotator muscles have been demonstrated. Typically, onset begins 1-5 years after insertion and is characterized by in- Computed Tomography creasing focal radiolucencies with adjacent local cortical thinning. This reac- cently [13], for example, measuring limb length and tion, as yet to have an agreed terminology (small-particle 110 I. Weissman disease is the most accurate), results from the shedding are at risk of fatigue and failure. Similarly, a poorly fixed of microparticles of cement, metal or polyethylene into metallic implant may be subject to metal fatigue. The exact histology varies Typically, this affects a femoral implant where poor fixa- according to particle size. Since, characteristically, no tion has been achieved, or has developed, proximally secondary bone response occurs, as in myeloma, at one while it it remains well fixed distally. However, prosthesis loosening may or may not be and fragment, the latter risking the development of present. To this end, a classification of degree and extent ly results from friction and, eventually, when the polyeth- of bone loss, from no notable loss of bone stock to ylene liner wears through or breaks, metal–metal abra- periprosthetic fracture, has been proposed [17]. This will be indicated by migra- Radiographically, the areas of radiolucency associated tion of an opaque element, such as the femoral head, rel- with this process are more difficult to assess around the ative to a fixed marker. It is important to distinguish wear knee, the distal femur being best assessed on lateral view. Creep represents normal Tibial lesions spread along screw tracks or around pe- plasticity of the cup, with central movement of the metal- ripheries of the tibial implants. Wear particles Abnormal Alignment and Dislocation cause a chronic low-grade synovitis and may result in small-particle disease. This is especially true with certain The postoperative position of a knee or hip replacement silastic implants. For example, at the or become displaced either due to primary failure or sec- hip, a varus position risks failure. Similarly, the acetabular angle on the lateral view of either retroversion or more than 30° Heterotopic Bone Formation of anteversion risks dislocation. Materials, for example, cement fragments, may very rarely become postopera- It is common to see heterotopic new bone formation, as tively interposed, sometime after closed reduction of a it occurs in about 15-50% of hip replacements. The risk is greater in patients who had infection, trauma, previous Failure of Union at Trochanteric Osteotomy/Abductor hip surgery, ankylosing spondylitis or paralysis prior to Tendon Re-implantation surgery. Failure of re- classified by the Brooker score, from minor foci to com- implantation results in poor gait and abductor weakness. Various forms of therapy may be em- Patients with poor muscle tone or general debility are at ployed in patients who exhibit excessive new bone for- greatest risk. Cement Extrusion Fractures, Non-union and Wear Although relatively common, for example, around the ac- etabular cup, this is usually asymptomatic and thought to The insertion of rigid metallic implants focuses loading be unimportant. Occasionally, cement injected under of the skeleton at specific points, for example, the tip of pressure may travel into veins, such as branches of the the femoral stem, rather than loading a longer area of profunda femoris, but this is not considered dangerous. Hence, stress risers occur at these sites and may be Rarely, cement extrusion causes nerve, vessel, bowel or considered a normal, perhaps ‘usual’, finding. Orthopedics 25:187-189 Publications have linked the finding of a malignant tumor 13. Radiology sue tumours, most often malignant fibrous histiocytoma 224:477-483 [22]. Clin Orthop Rel Res 286:40-47 an associated malignancy, local or general, is less than 15. Am J the knee in patients with the posterior stabilized condylar Roentgenol 181:1547-1550 knee prosthesis. Eur Radiol 11:2184-2187 Bone-ingrowth hip prostheses in asymptomatic patients: radi- 20. Nucl Med Comm 23:167-170 sis: a meta-analysis of 6 Nordic cohorts with 73,000 patients. J Bone Joint Surg (Am volume) 86- Weissman B (1997) Imaging of total hip replacement. Radiology Criteria for evaluation of the patient with painful hip or knee 222: 189-195 arthroplasty (www. The remaining patients 50-70% of patients initial radiography is performed in community hospi- should be evaluated with cross-sectional imaging. Some 10-14% of all spinal fractures and dislocations are associated with spinal cord injury. Injuries of the cer- vical spine are by far the ones most commonly associat- Imaging [3, 4] ed with neurological deficit which occurs in about 40% of these patients [1]. The majority of eral view should include all seven cervical vertebrae cord injuries are in the lower cervical spine and at the cer- along with the upper half of the T1 vertebra. Bony fragments within the spinal canal can al- Traumas of the Axial Skeleton 113 Table 1. Dynamic views (flexion and exten- spine (sagittal, T2-weighted): anterior subluxation of C on sion) are contraindicated in the acutely traumatized spine. After the initial emergency treatment, the long- dislocations term survival and quality of life of the patient depend on Mechansim Type Stable Unstable the stability of the injury. The three-column concept [5] was originally intended for Hyperflexion Anterior subluxation (sprain) + the thoraco-lumbar spine, but it can be used, with some Bilateral interfacetal dislocation + Simple wedge fracture + modifications, in the lower cervical spine (Table 4). Clay-shoveler’s fracture + According to this concept, fractures affecting both the ante- Tear-drop fracture + rior and middle columns or all three columns are considered Odontoid fracture + + unstable. Magerl’s classification is based on biomechanics Hyperextension Dislocation (sprain or strain) + and is divided into three grades of severity (Table 5). Taking Avulsion fracture of the + posterior arch of C1 Fracture of the posterior arch of C1 + Table 3. Radiographic findings of cervical spine instability Tear- drop fracture of C2 + Laminar fracture + ♦ Widened interspinous space or facet joints Hangman’s fracture + ♦ Anterior listhesis greater than 3. Components of the three columns of the cervical spine (after Denis) into account the mechanism of injury, cervical spine frac- Column Components tures and fracture dislocations can be divided into three ma- jor groups (Table 6). Anterior Anterior longitudinal ligament Anterior annulus fibrosus Hyperflexion injuries Anterior vertebral body Middle Posterior vertebral body Flexion injury of the cervical spine results in anterior an- Posterior annulus fibrosus Posterior longitudinal ligament gulation or translation of a vertebral segement in the sagittal plane. This injury is caused by direct trauma to Posterior Posterior elements the head and neck while the cervical spine is in a flexed Facet capsules Interlaminar ligaments (flava) position or by other forces that cause hyperflexion of the Supra- or interspinous ligaments cervical spine. Prominent features of flexion injuries are disruption of the posterior ligamentous complex including the in- Table 5. Components Radiological signs of Typ-A-/B-/C-injuries terlaminar ligaments, the facet joint capsules, and the of the thoraco-lumbar spine according to Magerl posterior part of the annulus fibrosus. In the acute phase, the injury can appear stable although the inci- Typ A injury Reduction of vertebral body height Compression fracture Body splitting dence of delayed instability is high, ranging from 20% A1 Impaction fracture Enlarge interpedicle distance to 50%. Hyperflexion injuries are commonly associated A2 Splitting fracture Intraspinal fragments with acute disc herniation. The flexion tear-drop frac- A3 Burstfracture ture is caused by severe flexion and axial loading. An anterior inferior corner (Injury of body and dorsal facett-joints fracture of the vertebral body is typically present. Cord parts with distraction) Overhanging dorsal edge B1 dorsal, ligament tear Transversal fracture injury is commonly associated with flexion tear-drop B2 dorsal, osseous tear Fragments of dorsal body-rim fracture (Fig. The clay-shoveler’s and the simple (fracture) wedge compression fracture tend to be stable, whereas B3 ventral tear trough disk the bilateral interfacetal dislocation and tear-drop frac- Typ C injury Lateralisation of body ture are unstable. Torsions injury Pedicle asymmetry When a significant rotational component accompanies (injury of body and dorsal Dislocation of spin. The vertebral body of the dislocated vertebra is an- C2 Type B-injury with rotation Fracture of dorsal ribs teriorly displaced. Widening of the interspinous process C3 Rotation and shearing Unilaterale fracture distance is present and the articulating facets are no Exarticulation longer in opposition (Figs. Traumas of the Axial Skeleton 115 Most commonly, this fracture occurs in frontal car acci- dents in which the driver and (or) passenger next to the driver did not use their seat belts (Fig. It often results from an anterior im- pact to the face or forehead or from sudden deceleration. Rupture of the anterior longitudinal ligament is frequently accompanied by disruption of the interver- tebral disc. An avulsion fracture of the anterior arch of the atlas and small extension tear-drop fractures can be seen in C2 and C3 with hyperextension injuries. In the more severe hyperextension injuries, at least two columns are disrupted, with resultant instability. Such fractures include the hangman’s fracture, which involves b the pedicles or posterior portion of the vertebral body of C2. There are anterior-flex- three types, depending on the location of the fracture [6]. Hyperextension of simultaneous disruption of the anterior and posterior injuries assume great importance in patients with anky- arches of C1 with or without rupture of the transverse at- losing spondylitis, and in patients with congenital or ac- lantal ligament. The Jeffersons fracture consists Atlanto-axial Fractures Odontoid fractures are the most frequent injury in the at- lanto-axial region. Anderson and D’Alonzo [7] classified odontoid fractures into three types based on the location of the fracture (Figs. The mech- Historically, the thoracic and lumbar spines were grouped anism is due to hyperextension and such fractures can oc- together, but based on anatomy and biomechanisms, they cur from relatively minor trauma [12]. The T -T supine swimmers view of the upper thoracic spine is al- 1 10 segment is distinguished by the presence of the rib cage, most always required for visualizing the upper three tho- which restricts motion and adds stiffness and stability to racic vertebrae. To produce a fracture in the upper thoracic sential for assessing vertebral alignment, height of the spine, considerable energy is required; therefore, such in- vertebral bodies, endplates and disc spaces. Attention juries are often associated with non-contiguous vertebral should be paid to the integrity of the lateral vertebral- fractures [8]. Of the patients with upper thoracic spine body margins, pedicles and posterior vertebral body line. The cord damage is believed to be Mediastinal widening is seen in more than two-thirds of due to the relatively small canal size and reduced blood patients with fractures above T5 and in such patients dif- ferentiating a thoracic spine fracture from aortic rupture supply to the mid-thoracic cord [10]. Scheuermann’s disease, is an abnormality of vertebral Extensive cord edema or focal cord hemorrhage are in- growth cartilage that results in vertebral wedging which dicative of a poor prognosis [14]. Thoracolumbar Junction (T11-L2) Injuries Classification of Upper Thoracic Spine Injuries Thoracolumbar spine injuries are common, accounting (T1-T10) for about 40% of all spinal fractures. In 1983, Denis proposed the three-column con- Fractures of the upper thoracic spine do not fit into the cept, in which the middle column is considered pivotal in Denis classification, which is intended for categorizing maintaining spinal stability [5]. Most injuries of umn concept, Denis also described four basic fracture the upper thoracic spine occur in flexion and axial load- types of the thoracolumbar junction. Bohlman classified these injuries in- sion fracture, burst fracture, flexion-distraction (Chance) to five types: (1) wedge compression, which is a com- fracture and fracture dislocation [5].

Total knee replacement: Posterior-cruciate-sparing or [3] A low joint line causes a low patella and may result cruciate-substituting designs may be inserted buy malegra dxt 130 mg with mastercard. Unicompartmental arthroplasty: The femoral and tibial Mobile tibial polyethylene bearings: Rotating platform components should parallel each other buy generic malegra dxt 130mg line, with no rotatory allows rotation discount 130 mg malegra dxt otc, meniscal bearings allow rotation and an- element buy 130mg malegra dxt otc, and lie parallel to floor. Constrained: Reserved for revision surgery, severe bone loss or after tumor resection. These devices do not permit knee rotation and are subject to failure (loosening) in pa- Bone In-growth and Porous Coating tients whose activity level is high. Porous coating, while significantly adding to the cost of Patellofemoral: Either as part of a total knee replacement, joint replacement, may significantly improve implant when a polyethylene “button” is cemented into the articu- longevity. Beads of a similar alloy are sintered onto the lar surface of the patella, or as a specific patellofemoral metallic components, permitting bony in-growth to occur joint replacement when the major knee compartments are without the need for intervening cement. Clearly, this requires stability to allow in-growth to occur, with implications for the postoperative period. Normal Appearances Anticipated normal plain-film appearances include re- sorption of medial femoral cortex at the calcar femoris Hip Replacements (98%), reduced bone density where it is unloaded, the ab- sence of a thin lucent rim around the implant, although The following features on plain film suggest an ideal po- such a lucency with a sclerotic margin is common (79%) sition for a total hip replacement. It is also normal to see endosteal sclerosis at the Acetabular anteversion should measure 0–30° on a true tip of a prosthesis (36%), localized periosteal new bone lateral view. The femoral component should be coaxial and cortical thickening, representing altered stress loading with the femoral shaft. Acetabular screws, if used, should (12%) and a degree of prosthetic subsidence (7%). The lucent line has Complications of Joint Replacement a sclerotic margin and develops during the first 2 years after insertion. A metal- joints, including pain and other symptoms, for which no bone lucency may be present immediately after surgery cause may be found. In addition, not all abnormal joint replace- quential radiographs for cemented devices whereas slight ments are associated with symptoms. Overall, complica- subsidence is acceptable, and part of the design in unce- tions occur in 1-5% of total hip replacements annually. The major complications are described in the follow- ing: Knee Replacements Loosening With or Without Coexisting Infection Alignment: Obtain standing views to check alignment and compare with earlier radiographs. The infection rate is approximately 1% of total hip replacements, 2% of Total knee: The tibial articular surface should be par- total knee replacements and 3% of revision joints per an- allel to the floor in a weight-bearing position. Obviously, figures vary but at 10 years after inser- femoral component should lie in 5-7° of valgus. The tion as many as 50% of hips may appear radiographical- patellar button should be central and well embedded in ly loose, 30% requiring revision [5]. The progressive similarly to 3-phase bone scan but less well than conven- widening of an interface, especially if associated with bone tional radiographs [8]. The presence of a joint effusion (shown on plain X-ray or ultrasound) implies a Arthrography joint that is abnormal, although a small joint effusion is usual in total knee replacements. Additional signs include The major objective of arthrography is to obtain fluid for excessive component migration or subsidence of unce- culture and sensitivity and to document intra-articular mented components, subsidence of cemented components, needle position. It is important to remember to aspirate cement or fatigue fractures of metallic components, dis- material for both aerobic and anaerobic cultures. A periosteal reaction should always be re- riostatic, aspiration prior to local anesthetic or saline in- garded as suspicious of infection, as opposed to local cor- jection is preferred. If the joint appears ‘dry’, or only a tical thickening, which represents a stress response. False-positive and false-nega- ing may be extremely difficult but features that suggest tive cultures occur, and thus synovial biopsy is preferred infection include excessive bone destruction, the radiolu- by some authors. As empha- as a therapeutic trial (does this ablate the pain of which sized, periosteal new bone formation is highly suggestive the patient complains? However, in- The sensitivity of arthrography is increased when con- fection is often low grade and associated with a non-vir- trast medium is injected under pressure (with local anes- ulent organism, and may be difficult to detect. Further Investigations Features shown on arthrography include loosening, component failure and extra-articular collections and Scintigraphy [5] tracks. Specific signs at the acetabulum of loosening in- clude the leakage of contrast at the cement-bone/metal- Bone-seeking 99mTc compounds demonstrate abnormal up- cement interface in 90% of loose replacements and ex- take for 9-12 months post-operatively. Abnormal activi- Femoral loosening is confirmed in about 98% by contrast ty in the blood pool or perfusion phase should suggest in- medium tracking into the cement-bone interface below fection, particularly if the abnormality is diffuse. In the late the intertrochanteric line, or in the bone-metal interface phase, the classical 3-point scan suggests varus tilt and below the intertrochanteric line. Again, a diffuse increase in activity suggests in- stemmed devices, contrast medium below the level of fection; however, the ability to separate infection from asep- mid-component is abnormal. A normal bone scan has a hip include communication with greater trochanteric bur- strong negative predictive value. However, for reasons that sae (50%), supra-acetabular collections (33%) and filling have yet to be explained, bone scans are often abnormal in of the iliopsoas bursa (17%). Lymphatic filling remains a otherwise uncomplicated total knee replacements and thus controversial finding and is probably not significant, al- have a poorer positive predictive value. It had a high neg- At the knee, contrast under the tibial tray, or the cement ative predictive value but a poor positive predictive val- interface is abnormal. The finding of a 111Indium labeled white blood cells afford increased Baker’s cyst may explain a patient’s symptoms and signs, sensitivity and specificity when used in combination with but in most cases is not relevant. Aspiration was shown to 99mTc bone scans but also carry a significant false-nega- be 100% sensitive and specific for infection in the knee in tive rate. The overall sensitivity is 86% with a ment of total hip and total knee replacements because of specificity of 78% [7]. Generally, the artefacts produced by a prosthesis re- alignment pre-operatively especially, in patients with flect the orientation of the prosthesis relative to the main fixed flexion deformities and in prosthesis planning. It is recommended that scans are obtained of the device and reducing voxel size (increasing the num- perpendicular to the femoral and tibial components in or- ber of pixels in the frequency-encoding direction does this der to assess rotation [14]. The use of less relation to a horizontal baseline, is normally between 0 and ferromagnetic hardware (e. Signs of the lat- shown by low-signal fluid collections adjacent to a com- ter include periostitis (100% specificity, but 16% speci- ponent, for example, paralleling the femoral stem. Poorly ficity for infection), soft-tissue infection (100% sensitiv- defined hyperintense areas suggest infection, with signal ity and 87% specificity) and the presence of fluid collec- intensity similar to fluid [10]. The latter is associated with focal cies, where it has been shown to be more sensitive than osteolysis and appears as discrete, well-demarcated inter- radiographs in detecting and quantifying acetabular mediate to slightly increased signal areas with low-signal small-particle disease [15]. Granulomas may appear as focal periprosthetic in- What investigations Are The Most Useful? College of Roentgenology (see National Guideline Peripheral enhancement and some internal enhancement Clearing House) are as follows, graded (1=least useful, have been noted [1]. For possible loosening, with or without infection, but The recent adaptations suggest that periprosthetic soft tis- radiographs normal: joint aspiration with or without an sues may be visualized better [10]. Other complications that may be demonstrated include The radiographs suggest loosening, but is the joint in- hematomata, fat-pad scarring and heterotopic bone forma- fected also? These criteria are currently being tensity and contrast enhancement decrease while the fat and reevaluated. In patients in whom re- current dislocation is a problem, the absence of the posteri- Small-Particle Disease or capsule and disruption of external rotator muscles have been demonstrated. Typically, onset begins 1-5 years after insertion and is characterized by in- Computed Tomography creasing focal radiolucencies with adjacent local cortical thinning. This reac- cently [13], for example, measuring limb length and tion, as yet to have an agreed terminology (small-particle 110 I. Weissman disease is the most accurate), results from the shedding are at risk of fatigue and failure. Similarly, a poorly fixed of microparticles of cement, metal or polyethylene into metallic implant may be subject to metal fatigue. The exact histology varies Typically, this affects a femoral implant where poor fixa- according to particle size. Since, characteristically, no tion has been achieved, or has developed, proximally secondary bone response occurs, as in myeloma, at one while it it remains well fixed distally. However, prosthesis loosening may or may not be and fragment, the latter risking the development of present. To this end, a classification of degree and extent ly results from friction and, eventually, when the polyeth- of bone loss, from no notable loss of bone stock to ylene liner wears through or breaks, metal–metal abra- periprosthetic fracture, has been proposed [17]. This will be indicated by migra- Radiographically, the areas of radiolucency associated tion of an opaque element, such as the femoral head, rel- with this process are more difficult to assess around the ative to a fixed marker. It is important to distinguish wear knee, the distal femur being best assessed on lateral view. Creep represents normal Tibial lesions spread along screw tracks or around pe- plasticity of the cup, with central movement of the metal- ripheries of the tibial implants. Wear particles Abnormal Alignment and Dislocation cause a chronic low-grade synovitis and may result in small-particle disease. This is especially true with certain The postoperative position of a knee or hip replacement silastic implants. For example, at the or become displaced either due to primary failure or sec- hip, a varus position risks failure. Similarly, the acetabular angle on the lateral view of either retroversion or more than 30° Heterotopic Bone Formation of anteversion risks dislocation. Materials, for example, cement fragments, may very rarely become postopera- It is common to see heterotopic new bone formation, as tively interposed, sometime after closed reduction of a it occurs in about 15-50% of hip replacements. The risk is greater in patients who had infection, trauma, previous Failure of Union at Trochanteric Osteotomy/Abductor hip surgery, ankylosing spondylitis or paralysis prior to Tendon Re-implantation surgery. Failure of re- classified by the Brooker score, from minor foci to com- implantation results in poor gait and abductor weakness. Various forms of therapy may be em- Patients with poor muscle tone or general debility are at ployed in patients who exhibit excessive new bone for- greatest risk. Cement Extrusion Fractures, Non-union and Wear Although relatively common, for example, around the ac- etabular cup, this is usually asymptomatic and thought to The insertion of rigid metallic implants focuses loading be unimportant. Occasionally, cement injected under of the skeleton at specific points, for example, the tip of pressure may travel into veins, such as branches of the the femoral stem, rather than loading a longer area of profunda femoris, but this is not considered dangerous. Hence, stress risers occur at these sites and may be Rarely, cement extrusion causes nerve, vessel, bowel or considered a normal, perhaps ‘usual’, finding. Orthopedics 25:187-189 Publications have linked the finding of a malignant tumor 13. Radiology sue tumours, most often malignant fibrous histiocytoma 224:477-483 [22]. Clin Orthop Rel Res 286:40-47 an associated malignancy, local or general, is less than 15. Am J the knee in patients with the posterior stabilized condylar Roentgenol 181:1547-1550 knee prosthesis. Eur Radiol 11:2184-2187 Bone-ingrowth hip prostheses in asymptomatic patients: radi- 20.

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The presence of old cheap malegra dxt 130mg on line, disintegrating storm and sanitary sewers cheap 130 mg malegra dxt with mastercard, misplaced sewer pipes order 130mg malegra dxt with amex, and good breeding conditions are common explanations for the high levels measured cheap 130 mg malegra dxt otc. Waterborne Diseases ©6/1/2018 117 (866) 557-1746 Indicator Connection Varies General coliforms, E. Coli, and Enterococcus bacteria are the "indicator" organisms generally measured to assess microbiological quality of water. Because it is so much more expensive and tedious to do so, actual pathogens are virtually never tested for. Over the course of a professional lifetime pouring over indicator tests, in a context where all standards are based on indicators, water workers tend to forget that the indicators are not the things we actually care about. They are of little concern at low levels, except to indicate the effectiveness of disinfection. At very high levels they indicate there is what amounts to a lot of compost in the water, which could easily include pathogens (Ten thousand general coliform bacteria will get you a beach closure, compared to two or four hundred fecal coliforms, or fifty enterococcus). They are another valuable indicator for determining the amount of fecal contamination of water. The more closely related the animal, the more likely pathogens excreted with their feces can infect us. Human feces are the biggest concern, because anything which infects one human could infect another. Keep in the back of your mind that the ratio of indicators to actual pathogens is not fixed. Whenever you are trying to form a mental map of reality based on water tests, you should include in the application of your water intuition an adjustment factor for your best guess of the ratio between indicators and actual pathogens. Waterborne Diseases ©6/1/2018 118 (866) 557-1746 Common Water Labortory Procedures Photographs This lab equipment is used for testing parameters in water such as Metals, Pesticides and Hydrocarbons. Often geotechnical water testing that is performed to support characterization regarding the fate and transport of contaminants in soils and sediments. Information such as the grain size distribution provides insight into the absorption, accumulation and movement of contaminants as it may relate to various particle sizes. Waterborne Diseases ©6/1/2018 119 (866) 557-1746 Top Photo: Extraction is a process used to concentrate trace levels of materials, in this case metals. Bottom Photo: Atomic absorption requires the presence of ground state metal atoms (Me ). The initial process which takes place in an atomic absorption spectrophotometer iso to create a population of ground state atoms. This is accomplished in a variety of ways, usually classified as flame and non-flame. Low detection limits were developed to support risk assessment, Mercury bioaccumulation in fish is a heightened concern. Thirty-nine states have issued fish consumption advisories due to mercury contamination. Mercury is a toxic pollutant across most regulatory programs (air, water, hazardous waste & pollution prevention). It is persistent and harmful to human health and the environment at relatively low levels. Waterborne Diseases ©6/1/2018 122 (866) 557-1746 Prepared samples stored for metal analysis. Waterborne Diseases ©6/1/2018 123 (866) 557-1746 Top Photo: This form shows a typical ion chromatography run will have a standard curve consisting of 4 or 5 points for each ion of interest. The coefficient is calculated by plotting the peak area against the standard concentration using a linear fit. Waterborne Diseases ©6/1/2018 125 (866) 557-1746 Top Photo: Collecting the seed in a 500 ml bottle and let settle at least 1 hour and up to 36 hours. This will allow settleable solids to settle and help assure the seed is homogeneous. Waterborne Diseases ©6/1/2018 126 (866) 557-1746 Top Photo: This area is used for Fecal coliform which the most common dilution is prepared by transferring 11 ml of sample to 99 ml of sterile phosphate dilution water using a sterile serological pipet. The broth and membrane used vary depending on the sample type for water or wastewater. Excessive turbidity in the sample will plug the membrane filter, causing poor bacteria recovery and slow filtration times. Waterborne Diseases ©6/1/2018 130 (866) 557-1746 Top Photo: Analytical funnels are 100 ml filtration units that allow the membrane to be removed. Waterborne Diseases ©6/1/2018 131 (866) 557-1746 Waterborne Diseases ©6/1/2018 132 (866) 557-1746 Water Quality & River Sampling Photos Top Photo: Technicians use several different devices to sample wells depending on the depth of the water table. The containers that look like milk bottles are used for the equal width depth integrated sampler. The methods typically result in a composite sample that represents the streamflow-weighted concentrations of the stream cross section being sampled. Waterborne Diseases ©6/1/2018 134 (866) 557-1746 The churn splitter was designed to facilitate the withdrawal of a representative subsample from a large composite sample of a water-sediment mixture. For example, samples from several verticals in a stream cross section, differing slightly from each other in chemical quality and sediment concentration, can be placed in the churn and be mixed into a relatively homogenous suspension, any subsample withdrawn from the churn should be equal in chemical quality and sediment concentration to any other subsample from the churn. Waterborne Diseases ©6/1/2018 135 (866) 557-1746 Ampullariidae, common name the apple snails, is a family of large freshwater snails, aquatic gastropod mollusks with a gill and an operculum. This family is in the superfamily Ampullarioidea and is the type family of that superfamily. The Ampullariidae are unusual because they have both a gill and a lung, the mantle cavity being divided in order to separate the two types of respiratory structures. Waterborne Diseases ©6/1/2018 136 (866) 557-1746 Top Photo: When sampling in the river it is suggested that a minimum of two people participate. One person is holding the collection net while the other carefully disturbs the sediment for collection. Bottom Photo: This river contained larvae of mayfly and stone flies along with leaches. Waterborne Diseases ©6/1/2018 137 (866) 557-1746 Sieving invertebrate samples reduces the volume of sediment that must be sorted through in the lab. A #60 sieve is recommended because the smaller invertebrates will be retained by the #60 sieve and should yield more complete invertebrate community data for a site. Any large debris should be cleaned (remove invertebrates and add them to the sample) and removed from the sample. The sample is then washed through the sieve over the side of the boat or in a tub with site water until no more fine sediment washes through the mesh. Waterborne Diseases ©6/1/2018 138 (866) 557-1746 Membrane Filter Total Coliform Technique The membrane filter total Coliform technique is used at Medina County for drinking water quality testing. These containers, when used for chlorinated water samples, have a sodium thiosulfate pill or solution to dechlorinate the sample. The sample is placed in cold storage after proper sample taking procedures are followed. No longer than 30 hours can lapse between the time of sampling and time of test incubation. Glassware in oven at 170 C + 10 C with foil (or other suitable wrap) loosely fitting ando o secured immediately after sterilization. Use sterile petri dishes, grid, and pads bought from a reliable company – certified, quality assured - test for satisfactory known positive amounts. Waterborne Diseases ©6/1/2018 139 (866) 557-1746 Plates can be stored in a dated box with expiration date and discarded if not used. Everclear or 95% proof alcohol or absolute methyl may be used for sterilizing forceps by flame. Filtration units are placed onto sterile membrane filters by aseptic technique using sterile forceps. A sterile padded petri dish is used and the membrane filter is rolled onto the pad making sure no air bubbles form. After 22- 24 hours view the petri dishes under a 10 –15 power magnification with cool white fluorescent light. Count all colonies that appear pink to dark red with a metallic surface sheen – the sheen may vary in size from a pin head to complete coverage. Anything greater than 1 is over the limit for drinking water for 2 samples taken 24 hours apart. Waterborne Diseases ©6/1/2018 140 (866) 557-1746 Water Sampling Terms and Definitions Microbes Coliform bacteria are common in the environment and are generally not harmful. However, the presence of these bacteria in drinking water is usually a result of a problem with the treatment system or the pipes which distribute water, and indicates that the water may be contaminated with germs that can cause disease. Microbes in these wastes can cause short- term effects, such as diarrhea, cramps, nausea, headaches, or other symptoms. However, turbidity can interfere with disinfection and provide a medium for microbial growth. These organisms include bacteria, viruses, and parasites that can cause symptoms such as nausea, cramps, diarrhea, and associated headaches. Cryptosporidium is a parasite that enters lakes and rivers through sewage and animal waste. However, the disease can be severe or fatal for people with severely weakened immune systems. Giardia lamblia is a parasite that enters lakes and rivers through sewage and animal waste. Certain minerals are radioactive and may emit a form of radiation known as alpha radiation. Certain minerals are radioactive and may emit forms of radiation known as photons and beta radiation. Radon gas can dissolve and accumulate in underground water sources, such as wells, and in the air in your home. Inorganic Contaminants Antimony Cadmium Cyanide Nitrite Asbestos Chromium Mercury Selenium Barium Copper Nitrate Thallium Beryllium Waterborne Diseases ©6/1/2018 141 (866) 557-1746 Arsenic. Dental fluorosis, in its moderate or severe forms, may result in a brown staining and/or pitting of the permanent teeth. Waterborne Diseases ©6/1/2018 142 (866) 557-1746 Water Sampling and Laboratory Procedures Before we can identify our waterborne disease, we first must sample the water. Most of you are very familiar with water sampling and may skip this section and proceed to the other chapters. Proper collection and handling of a water sample is critical for obtaining a valid water test. Sample containers should always be obtained from the testing laboratory because containers may be specially prepared for a specific contaminant. Sampling and handling procedures will depend on the specific water quality concern and should be followed carefully. If the water is being treated, it may be necessary to sample both before and after the water goes through the treatment equipment. Clean sample containers, preservatives and coolers are generally provided by most laboratories. Contact the laboratory about a month before the sampling date to schedule analyses and container shipment or pickup. Collecting water-quality samples involves not only the process of physically acquiring the best possible sample for the intended analysis, but also characterizing the environment from which the sample was drawn, and handling the sample so as to protect its value for its intended purpose.

These results indicated that acupuncture could suppress the increase in c-Fos expression and 249 Acupuncture Therapy of Neurological Diseases: A Neurobiological View extent of apoptosis induced by ischemia generic 130mg malegra dxt amex. These results are somewhat consistent with those obtained by Dong and Chen (2001) discount 130mg malegra dxt mastercard. Acupuncture was observed to suppress the overexpression of c-Fos at each time point that they studied and reduce the volume of ischemic infarction buy cheap malegra dxt 130mg on-line. Furthermore malegra dxt 130mg, in the acupuncture-treated group, after the microinjection of c-Fos antisense oligonucleotide into the ischemia core, there was an increased infarction volume with the overexpression of c-Fos being completely blocked, when compared with the acupuncture-treated group without antisense oligonucleotide microinjection. The therapeutic correction directed toward modulation of inflammatory immune response at the level of cytokine expression may be a necessary factor for the prevention and treatment of stroke, as well as for the successful rehabilitation of stroke patients (Arekelian et al. Some studies showed that acupuncture may have the potential to regulate inflammatory processes of ischemia or stroke (Chen et al. Free radicals formation With an unpaired electron in the outer shell, free radicals are very unstable and highly reactive, and in turn, can cause serious damage to the neurons. Furthermore, the production of large numbers of free radicals is frequently associated with excitotoxicity. These results are consistent with other studies published in some Chinese journals (Bai et al. However, the normal functioning of these antioxidant enzymes may be insufficient for the prevention of oxidant-induced peroxidation of the membrane lipid. Apoptotic signals Several articles showed that acupuncture may have a potential to reduce the number of neuronal cells undergoing apoptotic cell death (Shi 1999; Wang et al. It is hypothesized that acupuncture has the potential to rebalance such signals in stroke therapy. Subsequently, the expression progressively decreased and almost reached the baseline at 24 h post-reperfusion. These cells were observed at 8 h post-reperfusion and increased at 24 h post-reperfusion. Effect of acupuncture on neurogenesis It is confirmed that neural stem cells are also distributed in the adult brain, and are able to proliferate and finally differentiate into neurons or glial cells. Cerebral ischemia is observed to induce cell proliferation, migration, and maturation. However, it is still a challenge for neurologists to develop a method to promote the neurogenesis and neural functional recovery. A few studies have been attempting to implant exo-stem cells or provide stimulants to trigger inherent proliferation of the stem cells to compensate for the dead neurons in the injured brain region. In clinical practice, acupuncture is commonly used to promote functional recovery in the treatment for paralysis. These findings indicate that acupuncture might have the ability to promote cell proliferation after ischemia. The DiI is a lipophilic neuronal tracer and was intravenously injected after ischemia. The tri-labeling of these cells suggest that newborn striatal neurons might migrate mainly from the cells lining the ventricle. Evans Blue extroversion reached its first peak at 6 h post-reperfusion and second peak at 48 h post-reperfusion. Physicians are advocated to perform multiple interventions of combined agents and give prescriptions personally, as multiple factors including inflammatory, excitotoxicity, and free radicals are involved, which cross-react in the injury cascade of ischemia. Acupuncture, unlike chemical drugs, may be a useful option, because it is a convenient and cost-effective modality with low side effects. In fact, acupuncture has been widely used for stroke therapy in oriental countries, and has become more and more popular in the western countries. Most studies suggest that patients show better outcome and require less nursing and rehabilitation therapy after acupuncture treatment. In some clinic trials as well as experimental studies in China, the combination of acupuncture and other neuroprotective agents has been observed to exert better outcome than acupuncture or neuroprotective agents alone. Therefore, a therapy combined with acupuncture and drugs may be a more effective way to treat stroke patients. However, there are several shortfalls in the currently published clinical data that render physicians unwilling to consider acupuncture therapy at the bedside. A multiple-center clinical trial with strict control is in urgent need to validate the efficacy of acupuncture therapy for stroke. In contrast to the extensive clinical application, experimental studies on acupuncture therapy with current techniques are still in its early stage. However, the available data do suggest that acupuncture might be a regulator to mobilize the mechanisms of self-regulation and self-repair in the brain, that is, ischemia is considered to trigger injury/death signals, while acupuncture is believed to augment the inherent survival mechanisms and antagonize the signals harmful to the brain. More comprehensive and mechanistic investigation will certainly generate invaluable information for better clinical practice of acupuncture therapy against stroke, and may even provide novel clue for the development of new solutions for the treatment of hypoxic-ischemic encephalopathy. Stroke 24: 16 19; discussion 110 112 Chao D, Donnelly D, Feng Y, Bazzy Asaad A, Xia Y (2006a) Cortical į opioid receptors + potentiate K homeostasis during anoxia and oxygen glucose deprivation. SfN Abstract 36 255 Acupuncture Therapy of Neurological Diseases: A Neurobiological View Chao D, Bazzy Asaad A, Balboni G, Xia Y (2007) į , but not ȝ , opioid receptor stabilizes K+ homeostasis by reducing Ca2+ influx in the cortex during acute hypoxia. Zhong Guo Zhen Jiu (Chinese Acupuncture and Moxibustion) 4: 13 (in Chinese) Gao H, Guo J, Zhao P, Cheng J (2002) The neuroprotective effects of electroacupuncture on focal cerebral ischemia in monkey. Acupunct Electrother Res 27: 45 57 Gosman Hedstrom G, Claesson L, Klingenstierna U, Carlsson J, Olausson B, Frizell M, Fagerberg B, Blomstrand C (1998) Effects of acupuncture treatment on daily life activities and quality of life: A controlled, prospective, and randomized study of acute stroke patients. Polarographical depth electrode recordings in evolving and completed experimental stroke in the monkey. Stroke 32: 707 713 Kagitani F, Uchida S, Hotta H, Sato A (2000) Effects of nicotine on blood flow and delayed neuronal death following intermittent transient ischemia in hat hippocampus. Neurosci Lett 297: 21 24 257 Acupuncture Therapy of Neurological Diseases: A Neurobiological View Kiyota Y, Takami K, Iwane M, Shino A, Miyamoto M, Tsukuda R, Nagaoka A (1991) Increase in basic fibroblast growth factor like immunoreactivity in rat brain after forebrain ischemia. Neurol Res 23: 47 50 Pang J, Itano T, Sumitani K, Negi T, Miyamoto O (2003) Electroacupuncture attenuates both glutamate release and hyperemia after transient ischemia in gerbils. Effect of brain derived neurotrophic factor treatment and forced arm use on functional motor recovery after small cortical ischemia. Shi J (1999) A study on the effect and mechanism of acupuncture suppression of neuronal apoptosis following cerebral ischemia. Shanghai Journal of Traditional Chinese Medicine 42: 71 74 (in Chinese with English abstract) Uchida S, Kagitani F, Suzuki A, Aikawa Y (2000) Effect of acupuncture like stimulation on cortical cerebral blood flow in anesthetized rats. Zhong Guo Zhen Jiu (Chinese Acupuncture and Moxibustion) 4: 37 38 (in Chinese) Xiong L, Yang J, Wang Q, Liu Y (2004) Cerebral ischemic tolerance induced by repeated electroacupuncture involved delta opioid receptor and enkephalin in rats. Clinical data suggest that the efficacy of acupuncture therapy varies depending on multiple factors, including the type of diseases, acupoints selected, and the manner of manipulation used. In general, acupuncture induces a much better efficacy in the patients with arrhythmia related to neural dysfunction than in those with pathological changes in the heart. The mechanistic research shows that acupuncture signal is mainly transferred to the central nervous system by afferent nerve fibers. The input signal leads to serial changes in electrical and chemical activities in the brain. Subsequently, the body corrects cardiovascular dysfunctions through neural regulation, endocrine secretion, humoral and dielectric regulation, intracellular modulation of signal transduction, and even gene expression. Thus, acupuncture induces a therapeutic effect on cardiovascular system through an integrated and complex mechanism. Keywords cardiac diseases, arrhythmia, acupuncture therapy, correction, mechanism 10. As early as in the Huangdi Neijing (the Section of Lingshu·Wuxie), it was perceptively recorded that “if there is evil in the heart, epigastric pain is felt and the patient is susceptible to sorrow, often feels dizziness or falls in asphyxia or syncope. Acupuncture Therapy of Neurological Diseases: A Neurobiological View meridian according to its state of excess or deficiency”. In the Wei and Jin dynasties, Huangfu Mi had already mentioned cardiodynia, and had referred to dizziness and cardiopalmus in his work, Zhenjiu Jiayi Jing (Acupuncture A & B Guidelines, Fig. It is noteworthy that in the 1960s 1970s, fruitful results in the field of acupuncture analgesia and anesthetization greatly promoted clinical and basic research on acupuncture therapy for cardiovascular diseases to a high level. In the recent years, acupuncture has increasingly become an active modality for cardiovascular diseases in China as well as other countries (Shi 1998; Zhu 1998; Cao 2001; Li and Man 2004; Tan 2005; Liu 2005; Chen and Xu 2009). Yellow Emperor’s Classic of Medicine (Huangdi Neijing) is the most important book on ancient Chinese medicine. Another book called Zhenjing (Classic of Acupuncture) is a classic book describing the Yellow Emperor’s Classic of Medicine. Zhenjiu Jiayi Jing and Zhenjiu Da Cheng are both specialist manuals on acupuncture. We will seek to broadly reflect the profile of the studies in this field, in spite of the fact that we do not necessarily agree with all the views and conclusions in the original articles. The acupoints selected are often located at the Shaoyin Heart Meridian of the hand and Jueyin Pericardium Meridian of the hand, sacral region, and legs. Jiang (1994) treated 30 cases of children with premature systole, using acupuncture therapy. Among the sick children, 12 cases suffered from atrial extrasystole and 18 cases had ventricular extrasystole. In other 23 cases, the heart rate decreased after 5 10 min of acupuncture and completely returned to normalcy 265 Acupuncture Therapy of Neurological Diseases: A Neurobiological View after 2 3 times of treatment, without relapse during the follow-up period. Qiu and Chen (2003) treated chronic cardiopulmonary disease with arrhythmia by combining acupuncture and medical drugs, and demonstrated an efficacy rate of 93. All these data suggest that acupuncture has a broad effect on arrhythmia resulting from various causes. Furthermore, there are data suggesting that acupuncture has a better effect on “rapid” cardiac arrhythmia (e. In the recent years, there have been significant progresses in the acupuncture treatment of this disease. According to a clinical study in 2001 (Cao 2001), the total rate of “efficacy” was 56. Among them, most showed decreased level of 267 Acupuncture Therapy of Neurological Diseases: A Neurobiological View glyceryltrinitrate, with 46. In manual acupuncture, it has been suggested that the acupoints should be strongly stimulated by hand manipulation (Shi 1998). Some clinical reports showed that heart failure could be improved by acupuncture treatment. Li and Man (2004) randomly divided 60 patients with symptomless heart failure into two groups (30 patients per group) and treated them with western medicine and acupuncture, respectively. The efficacy was evaluated by determining the left ventricle ejection fraction, shortening fraction, and plasma brain natriuretic peptide before and after the treatment. Thus, they concluded that acupuncture treatment could improve cardiac function, like western medicine. Apparently, it may be a better option for some patients, as acupuncture is convenient and cost-effective with producing little side effects. Some researchers observed the therapeutic effect of acupuncture on viral myocarditis and rheumatic heart disease (Zhu 1998; Deng et al. The total effective rate was more than 88% in 150 patients with viral myocarditis. However, the efficacy needs to be further verified, because the patients received the treatment along with the Chinese herbal medicine (Li et al. Nevertheless, all the above mentioned data strongly suggest that acupuncture could induce a therapeutic effect on various cardiovascular diseases, including arrhythmia, coronary artery disease, and cardiac failure.