By T. Kirk. Luther College. 2019.

Cohort and case control studies buy protonix 20 mg online, give 14 additional buy protonix 20mg amex, though sometimes conflicting, evidence with respect to which dietary 15 factors have harmful or protective effects. Some of the inconsistencies come from 16 inadequate measures or stratification of dietary elements. Several 24 epidemiological studies have reported on increased odds ratio or relative risk 25 with increased consumption of fat. Comparing cancer mortality with national food 26 consumption reported a positive association with animal fat in 1986 (Rose et al. Case control and cohort studies 28 have not been as consistent with the association of fat (Dagnelie et al. The 35 regression rates for prostate cancer with disappearance of fat calories was signif- 36 icant p = 0 0001, with a relative risk estimate of essentially zero for a 60% fat 37 reduction in the diet. Compilation of polymorphisms being investigated for a role in 02 prostate carcinogenesis. Using only 28 prospective studies- randomized or cohort they reviewed the dietary evidence for 29 prostate cancer associations. The x axis gives the number of studies reporting either 30 inverse, null or positive associations on the y axis with particular dietary component 31 (Dagnelie et al. Other dietary factors were inconclusive, though high levels 36 of calcium [>2000 mg/day] appeared to be adverse (Dagnelie et al. Which 37 particular compound in the foods, and the amount needed to be protective is under 38 investigation. Recent studies have hypothesized that the calcium in 43 the milk products lower circulating levels of vitamin D, which may be protective 44 (Giovannucci, 2005; Chan et al. Meta-analysis of prospective cohort and intervention trials with diet and prostate cancer 17 (Dagnelie et al. Studies on cigarettes have been mixed, a 25 recent study has documented a moderate risk [O. Aspirin and non-steroidal 31 anti inflammatory drug consumption has had mixed results as to whether there 32 is a null or modest protective association (Habel et al. The primary endpoint of lung 02 cancer prevention was not realized, in the beta carotene arm there were more lung 03 and prostate cancers with a higher total mortality of 8%. In the alpha-tocopherol 04 [Vitamin E] arm but there was a reduction in prostate cancer, 99 versus 151 cases, 05 a reduction by approximately one third [34%]. Hemorrhagic strokes 07 in men with uncontrolled hypertension contributed to the higher mortality in the 08 vitamin E arm, there was a 45% increased risk during the trial (Albanes et al. In a post trial analysis there was a persistent protective effect of vitamin E 10 on prostate cancer after intervention, but diminished fairly rapidly- by the third year 11 (Virtamo et al. Finasteride has been used to treat bladder outlet obstruction from 02 prostate enlargement since 1992. The trial was 06 closed early as the primary endpoint of 25% prostate cancer reduction was achieved 07 in the arm treated with finasteride. Sub stratification of the cancer demonstrated 09 that in the finasteride arm 280 men had Gleason 7 or higher [37% of cancer, 10 6. Despite the overall reduction of cancer, the 12 use of finasteride has not been embraced because of concern over the increase in 13 higher Gleason grade cancers. It has been reported there is potential for grading 14 bias due to changes in architecture, nuclei and nucleoli seen in hormonally treated 15 prostate cancers that could potentially falsely up grade disease (Bostwick et al. Another explanation is that finasteride prevents low grade lesions, but not 17 high grade lesions, and coupled with the prostate volume reduction [up to 30%] 18 from finasteride there is an improved biopsy efficiency for higher grade lesions 19 (Carver et al. The concern is 20 that finasteride may alter biology and induce cells to become higher grade. Dutasteride [Avodart] is the dual 5 alpha reductase inhibitor, inhibiting 29 type 2, as does finasteride, but also type 1. Vitamin C and the multivitamin or their placebos are taken daily, while 43 vitamin E and beta-carotene or their placebos are taken every other day (Christen 44 et al. Men were randomized to one of four arms, either 03 200ug Selenium [L-selenomethionine] or 400 mg of [dl-alpha-tocopheryl acetate] or 04 neither or both. Intervention is a minimum of 7 years for the last participants and up 05 to 1011 years for those who entered early. This illustrates 21 two points-one that toxicity in healthy people with a drug to prevent a possible 22 cancer in the future is unacceptable. It 07 should be clarified that screening implies performing a test on an asymptomatic 08 man in the general population. First the 11 disease to be screened for should be a major health concern, second there should be 12 a health benefit for early intervention, third the screening test should be rapid and 13 inexpensive, and fourth the test should have high sensitivity and specificity. Autopsy series demonstrating large 16 numbers of men with clinically insignificant prostate disease give some concern 17 that aggressive treatment of prostate cancer is not indicated when so many men die 18 of other causes (Sakr et al. It is estimated that there will be 230,000 cases of 19 prostate cancer diagnosed in the U. Because of the slow growing nature of most prostate cancers and 22 the age of the men at diagnosis with other co morbidities, many feel early treatment 23 does not improve overall survival.

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Although apparently rare the condition has probably been frequently incorrectly diagnosed purchase 40mg protonix visa. Difficulties such as lack of consistency in diagnosis purchase protonix 40 mg without prescription, lack of agreement on case definition and differences in case finding methods have contributed to this. Prognosis is greatly improved if a child is placed into an intensive and highly structured educational program by age two or three. One of the changes has been the appreciation that several closely-related disorders exist; they share the same essential features but differ on specific symptoms, age of onset, or natural history. Although both the nomenclature and the criteria set used to define autism have changed over the years, these changes are not so great as to prevent comparative analysis and do not explain major differences in reported prevalence over time. The major source of variability in reported autism rates comes from incomplete ascertainment in young age cohorts, which limits the ability to detect an underlying and rising secular trend. Reviews that have downplayed the rising trend have overemphasized unimportant methodological problems and failed to take into account the most relevant biases in survey methodologies. Point prevalence comparisons made within and across surveys conducted in specific geographic areas, using year of birth as a reference for trend 59 assessment, provide the best basis for inferring disease frequency trends from multiple surveys. On May 9th, 1996, the European Parliament launched an official Declaration in which it urged the Commission to fully support any effort and project to develop the rights of people with autism. The study of risk factors has contributed to the prevention of other health problems e. Most of the risk factors have been identified in clinical studies by using different methods and populations. The inconsistent retrieval of data in these studies has made a direct comparison of risk factors very difficult. A systematic review of prevalence studies has contributed to explaining some of the influences on variation among prevalence estimates. Over half of the variation among study estimates can be explained by the age of the children screened, the diagnostic criteria used, and the country studied. Other important factors were whether the study was in a rural or urban location and whether cases were assessed prospectively or retrospectively. The impact of these known factors on prevalence estimates should now be further investigated as they may be acting as proxies for other influences on prevalence. Risk factors found in more than one of the populations as well as risk factors found to be associated in only one population will be included in the guide. The reason for including the unique factors in the guide is that the lack of association in other populations can be due 60 to different criteria or methods and not necessarily because of a direct lack of association. The authors conclude that better ascertainment of diagnosis is likely to have contributed to this increase but that a real increase cannot be ruled out. A study published in 2004 [2] looks at the different surveys carried out worldwide and suggests a precautionary approach and that the raise in incidence of autism should be a matter of urgent public concern. This is consistent with the upper end of prevalence estimates from previously published studies, with some communities having an estimate higher than those previously reported in U. This is a relevant action as there is no such existing Europe-wide information at present and such a study requires thorough planning for implementation after the current project. After building the first prevalence study design, a checklist will be developed for obtaining more detailed information from those countries/regions that express their willingness to participate in the pilot prevalence study. The checklist study will also provide inputs that could lead to the introduction of modifications in the prevalence study design. If so, this second draft of the prevalence study design will be analysed in a feasibility study in those countries/regions which meet all criteria previously stated in the checklist. This third field study, namely feasibility study, will provide the more important and detailed information for building the final prevalence study protocol. All the existing prevalence studies, including those using more comprehen- sive and reliable methods lead us to the following conclusions: 62 Prevalence is increasing, possibly not only due to increased awareness among population and professionals. Age of children, case ascertainment procedure and type and level of development of regions explored seem to be the most important variables that influence in this estimate figure. Controversy exists in the management of the disorder and cannot be entered into within the context of this report. It has been observed that there are very wide inequalities in terms of waiting lists for diagnosis, in countries where such services exist, often in the private sector and through Parents Groups. This work could be further developed and promoted to gain more knowledge in this area. Elevated death rates are due to several causes, including seizures, accidents and respiratory diseases among people with severe learning disability. The realisation of this goal has already laid its foundations, as the main actors in the project are among the world leaders in their disciplines. For adults with autism the highest costs are those generated by health and social care provision (59%), followed by lost employment (36%) and family expenses (5%). Although both the nomenclature and the classification criteria used to define autism have changed over the years, these changes do not prevent some comparative analysis and do not fully explain the major differences in reported prevalence over time. Tools have been developed for early detection and diagnosis of the disorders, particularly in the United States of America and Great Britain. At European level, however, the early detection and diagnosis of children with autism varies enormously from country to country.

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Vitamin E care buy 40mg protonix, and using respite opportunities to socialize and get and selegiline may also reduce the rate of decline in rest buy protonix 20 mg low price. Treating the behavioral complica- situations can also relieve stress and improve well-being. Medications should be tailored to both the individual patient and the accompanying constellation of symptoms and may Suggested Reading include: neuroleptics or antipsychotics (used to treat American Psychiatric Association. Benzodiazepines (diazepam or Valium, alpra- Quality Standards Subcommittee of the American Academy of zolam or Xanax, lorazepam or Ativan, and so forth) Neurology. Prevalence of neuropsychiatric symptoms in especially of paradoxical disinhibition (reaction of dementia and mild cognitive impairment. The diagnosis and differential of major depressive disorder requires a certain severity diagnosis of dementia. Medical Clinics of North America, 86, and duration of the symptoms for more than 2 weeks 455476. Incidence of dementia: Does gender Diagnostic and Statistical Manual of Mental Disorders, make a difference? Diagnosis and treat- feels sad or empty) or observations made by others ment of Alzheimer disease and related disorders. Depression This widely used term may be In making these diagnoses one must exclude those that referred to as a symptom, a syndrome, an illness, or a may be caused by other medical conditions and sub- disorder. Treatments have been mood and affect are very common and much of psy- based on the newer knowledge about causes, espe- chiatry is concerned with trying to define when a syn- cially in the area of development of new medications as drome reaches a threshold for becoming an illness and well as the refinement of many psychotherapies. Depressive illnesses require a cer- Mental disorders affect both men and women tain severity and duration of the symptoms in order to equally, but the patterns and presentations are often dif- qualify for a diagnosis. Much of what we from conditions that have not met formal diagnostic cri- know and much of the current research are not yet suf- teria. This situation is often referred to as sub-syndromal ficient to completely understand why these differences depression. Depressive disorders are the most common mental Starting in adolescence and extending through illnesses and are the second leading cause of disability menopause, women experience twice the rates of depres- in the Western world after heart disease. The diagnosis sive disorders (major depressive disorder, dysthymia, 210 Depression rapid cycling bipolar disease, and seasonal affective or harming others. Women also experience a feelings of helplessness, hopelessness, and being higher incidence of anxiety disorders such as phobias, trapped in some situation. Dysthymia is a more minor agoraphobia, panic disorder, generalized anxiety disor- mood change lasting for 2 years or more. Women often affective disorder is a mood change that occurs during have other mental disorders that accompany the depres- times of the year when there is less light. Rapid cycling sive ones, such as anxiety problems or alcohol and sub- bipolar disorder refers to a manic depressive illness stance abuse. Men tend to have higher rates of alcohol and where there are four or more episodes of mania or drug abuse. While the causes for week or more before the onset of menses and are usu- gender differences remain unclear some theories have ally relieved with bleeding. However, most likely explanation is that biological and psycho- about 45% of women experience much more severe logical factors may be involved. Since differences symptoms that can interfere with their functioning at appear between men and women in the likelihood of school, work, or with interpersonal relationships. Research is under way to clarify the relationship tribute to the gender differences in the rates of depres- of ovarian hormones to brain neurotransmitters, adrenal sion between men and women. Some of the normal psychological changes shown the effectiveness of preventive treatment by include anxiety, mood lability, and concerns about giving medications during pregnancy or right after bodily changes and well-being of the fetus. The most common symptoms are emo- distractibility, and inability to focus attention. These feelings come as hospitalization is indicated plus treatment with antipsy- a surprise to many women who are so pleased to have chotic medications as well as psychotherapy. Often, rest viduals should not be left alone until they show marked is helpful but no other special treatments are needed. Milder forms of period, which is a major hormonal transition like depressive illnesses are called adjustment reactions with puberty, may present women with more depressive and depressed mood. Recent always include a careful physical exam plus laboratory work interestingly suggests that women with major tests for thyroid function. It is important to Pregnancy weigh the risk benefits of use of medications in the pregnant and postpartum woman who is nursing. Some medications can be used safely and should be Suggested Reading carefully considered. This is a common con- Stasis dermatitis usually occurs on the lower legs dition that has a variety of different causes and presen- and is characterized by itchy red and scaly patches.

Lyme disease; inflammatory disorders including and the presence of oligoclonal bands protonix 40 mg online. Multiple In every patient with suspected sarcoidosis of southeastern part of the United States buy protonix 20 mg fast delivery. Optic neuritis occurs, especially in phenotyping of the washed cells, and liver or A slight preponderance is reported in females. The symptoms of the sarcoid granulomata as well as parenchymal peripheral nerve involvement are due to the lesions with disruption of the blood-brain barrier. Anecdotal reports of remissions systemic sarcoidosis, biopsy is the only method as well as flare-ups during pregnancy have been of diagnosis. However, patients with sarcoidosis can have increased susceptibility to mycobacterial infections. Cushingoid side effects can be Accordingly, encephalopathic patients may require steroids for disorders that require immediate minimized by reduction of oral salt intake. Oral prednisone The best guide to effective treatment is the clinical to prevent exposure keratitis. Patients with may be necessary in severe cases and is used in response of the individual patient. Patients with extensive basal meningeal clinical presentation is confusing and the sarcoidosis vary from 3 to 18 months, depending on the disease, endocrinopathy, or spinal cord is confined to the nervous system. In such instances response and steroid dependence exhibited by these granulomas often require more chronic therapy. However, these to 2,000-calorie low-carbohydrate diet to None specific for neurosarcoidosis. Diphosphonate therapy to reduce loss of bone mass, H2 Mockers for prevention of peptic Corticosteroid treatment can be associated with acid disease, and when appropriate, use of glucose intolerance and steroid-induced diabetes. In trimethoprim with sulfa for chemoprophylaxis rare individuals, aseptic necrosis of the femur can against Pneumocystis carinii should be considered. Arousal then increases muscle to various portable monitors for home diagnosis tone in the upper airway, relieving the obstruction. Am Fam Long-term cure rates with this procedure are less than 50%, and many patients ultimately require Physician 1999;60(8):2279-2286. Two pain syndromes are described: Metachromatic leukodystrophy: incidence estimated Episodic painful, burning sensations in the hands at 1 in 100,000 births. Sex attacks and cerebral hemorrhage, from mul- lipids that accumulate in tissues and organs of tifocal small vessel involvement. Reddish- affected individuals are from the normal turnover of Because of X-linked inheritance, patients with Fabry purplish angiokeratoma on the skin, which cells and cell components. Female heterozygotes may manifest may be limited to the umbilical and scrotal of the accumulating substances as well as the type symptoms of the disease but symptoms are less areas. Hypohidrosis and characteristic of tissue in which a particular lipid component is severe and of later onset. A cherry red phenotypes that correlate with the level of residual The sphingolipidoses are inherited in an autosomal- spot is present in 50% of patients. Central and/or peripheral nervous recessive manner except for Fabry, which is X- spasticity, rigidity, and vegetative state. Determination of carrier status is possible Hepatosplenomegaly, foam cells in bone marrow. Some and associated with variable neurologic and systemic patients have hepatosplenomegaly. Among non-Jews, the disease cranial nerve involvement with strabismus, facial incidence is 100 times less. Hepatosplenomegaly do exist: Switzerland, Japan, the Pennsylvania Dutch and bone lesions. Lower motor neuron involvement, Saskatchewan, Lebanese-Canadians, as well as in The sphingolipidoses must be differentiated which manifests as hypotonia and muscular Lebanon. Incidence of 1% in this progressive weakness and loss of previously nervous system. A cherry red spot is present in almost all form with onset at age 1 to 2 years, with Ashkenazi Jews. Seizures usually develop by the end of progressive ataxia, hypotonia, and diminished a predilection for the population of the first year. Incidence of 6 in 1,000 births in a before 6 months of age followed by progressive increased. Hepatosplenomegaly is almost * Niemann-Pick types C/D do not share this common always present.

It was only on this day order protonix 20 mg on-line, seven months after his arrival order 40mg protonix fast delivery, that he allowed himself to repeat the exact words of his doc- tor at home: You will die. When he arrived August 3, his alk phos was clearly elevated, but was it due to his status as a young growing boy? But there is a cyst remnant remaining, a calcified pineal to rescue and, ultimately, a shunt to remove. There was no hint of devel- oping mental impairment, although she was eighty-five now. She walked with ease; in fact, she had fallen re- cently at home without the slightest injurycontrasting with the frequent breaks she used to endure in the past. She had agreed to a follow-up bone scan even Katherine Morales three years later though bone density does not improve enough to show decisively on an X-ray, after bone cancer clears up. I thought that surely a little improvement in bone density would be visible, though. I searched for all the amino acids in her brain, since she seemed so young in attitude. She had no pockets of streptococcus bacteria throughout her body to make phenol: only in her joints were they Positive. L-ascorbic acid Positive L-threose Negative dehydroascorbic acid (oxidized) Negative D-threose Negative glutathione Positive L-xylose Negative glutathione (oxidized) Negative D-xylose Negative ferrous gluconate Positive L-lyxose Negative ferric phosphate (oxidized) Negative L-cysteine Positive iron sulfide FeS Positive L-cystine (oxidized) Negative iron sulfide FeS2 (oxidized) Negative She was not over-oxidized! Surely she was benefiting from this diet the way our patients benefit from the chicken broth that is part of their 21 Day Program. Especially along the back of the head and neck and upper spine; the bone appears entirely normal. Summary: Katherine worked hard to recover from the bone cancer that gave her painful lesions, too numerous to count three years ago. She had denturesshe was not burdened with the extra toxicity of metal, plastic, or infections of the jaw that come with numerous restorations. Besides this, the extra high doses of rhodizonate she took initially surely would have detoxified the food dyes accumulated in her body. We knew nothing about them at that time; we now accomplish this with co- enzyme Q10 and vitamin B2. After overcoming her bone cancer, she not only became well, but extraordinarily well. She Last bone scan had two unusual habits: zapping daily for three years and a diet rich with chicken soup. Do you then heave a sigh of relief and say, Great job, now they will never be back? Parasite or pathogen-caused diseases are bound to come at you again and again, so a long term follow-up by itself makes little sense. The whole con- cept of Long Term Follow Up for cancer is faulty and should be abandoned. A follow up of parasitism and infection plus tissue levels of heavy metals, solvents, dyes and our sulfur reserves makes more sense. Seeing that cancer in all its forms has external causes and is not due to degenerative disease related to aging brings back hope. And I hope you got a good sense of how to accomplish the impossible, and in some cases, how easy it can be! To achieve this with ease and efficiency, you will need to equip the kitchen with: A stainless steel pressure cooker and glass bowls with lids to fit inside. To fry use glass or enamelware; occasional (once a week) use of Teflon or Silverstone is allowable. Do not use special sprays to grease; they contain silicone, which I detect in tumors. Dont overheat unsaturated fats All fruits and vegetables were grown in soil that was fertil- ized and had filth in it. Even chicken eggs, though shielded by bacteria-proof shells, have rabbit fluke within! Only a few fruits are so safe they dont need extra caution: watermelon, cantaloupe, and honeydew melon. The thinner- peeled fruits, including bananas, avocados, and citrus require careful sanitizing. These fail to kill rabbit fluke and Ascaris eggs, although they do kill many pathogens. Not merely pressure-cooking, which kills more, but still fails to kill Ascaris eggs in hard foods. Roasted meats or turkey, even if oven-baked, are not safe; the temperature did not go high enough. Although the temperature may have been set at 400, the food in the oven is considered done at 185F and lower! With- out heat or equipment and, while eating with dirt-laden hands, the food is sterilized.

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Morphology of infarcts Gross: All infarcts are wedge-shaped with the occluded vessel at the apex and the periphery of the organ forming the base of the wedge discount protonix 40mg fast delivery. Following inflammation discount protonix 40 mg with visa, some of the infarcts may show recovery, however, most are ultimately replaced with scars except in the brain. Microscopy: The dominant histologic feature of infarction is ischemic coagulative necrosis. The brain is an exception to this generalization, where liquifactive necrosis is common. Myocardial infarction Usually results from occlusive thrombosis supervening on ulcerating atheroma of a major coronary artery. Cerebral infarcts May appear as pale or hemorrhagic A fatal increase in intracranial pressure may occur due to swelling of large cerebral infarction, as recent infarcts are raised above the surface since hypoxic cells lack the ability to maintain ionic gradients & they absorb water & swell. Splenic infarcts - Conical & sub capsular - Initially dark red later turned to be pale. Tissue thromboplastin substance may be derived from a variety of sources such as: A: Massive trauma, severe burns & extensive surgery. B: Obstetric conditions in which thromboplastin derived from the placenta, dead retained fetus, or amniotic fluid may enter the circulation. Endothelial injury: Widespread endothelial injury may result from: - Deposition of antigen-antibody complexes as it occurs in systemic lupus erythematosus - Extreme temperature eg. This may lead to ischemia of the more severely affected or more vulnerable organs and hemolytic anemia resulting from fragmentation of led cells as they squeeze through the narrowed microvasculature (Microangiopathic haemolytic anaemia). Second, a hemorrhagic diathesis may dominate the clinical picture because of consumption of the coagulation factors and increased fibrinolysis. The onset may be fulminant when caused by endotoxic shock or amniotic fluid embolism or it may be chronic in the case of carcinomatosis or retention of dead fetus. Shock Definition: Shock is a state in which there is failure of the circulatory system to maintain adequate cellular perfusion resulting in widespread reduction in delivery of oxygen & other nutrients to tissues. In shock, the mean arterial pressure is less than 60 mmHg or the systolic blood pressure is less than 90 mmHg. The end results are hypotension followed by impaired tissue perfusion and cellular hypoxia. Reduction in circulating blood volume results in the reduction of the preload which leads to inadequate left ventricular filling, reflected as decreased left & right ventricular end diastolic volume and pressure. The reduced preload culminates in decreased cardiac out put which leads to widespread tissue perfusion (shock). Causes of hypovolumic shock include: a) Haemorrhage b) Diarrhoea & vomiting c) Burns d) Trauma e) etc The effect of haemorrhage depends on the rate and amount of blood loss. A normal healthy adult can lose 550ml (10%of blood volume) without significant symptoms. But loss of 25% or more of the blood volume (N=1250ml) results in significant hypovolemia. Cardiogenic shock Definition: This is shock that results from severe depression of cardiac performance. Usually shock occurs in this conditioin if 40% of the left ventricular mass & more on the right ventricle is involved by infarction. Aortic stenosis, hypertrophic cardiomyopathy b) Reduction in forward cardiac output E. Aortic or mitral regurgitation c) Arrhythmia ii) Extracardiac This can be called obstructive shock. Distributive shock Definition: Distributive shock refers to a group of shock subtypes caused by profound peripheral vasodilatation despite normal or high cardiac output. Causes of distributive shock 1) Septic shock the commonest among the group & clinically very important. But before discussing septic shock in detail it would be useful to know some aspects of sepsis briefly. Bactermia is the presence of viable bacteria in the blood as evidenced by blood culture. Septicemia is systemic infection due the presence of microbes and their toxin the blood. Sepsis is a systemic response to severe infection mediated via macrophage-derived cytokines that target end organ receptors in response to infection. Septic shock Definition: This is a kind of shock caused by systemic microbial infection, most commonly by gram negative infection (endotoxic shock) but can also occur with gram positive or fungal infections. Hypotention, arterial blood pressure less than 90mmHg or 40mmHg less than the patients normal blood pressure, 2. It results from the spread & expansion of an initially localized infection like pneumonia into the blood stream.

So Patson was given a bus warrant purchase 40 mg protonix with mastercard, and a note to the orthopaedic surgeon in the teaching hospital in the capital city buy protonix 20 mg on-line. The Land Rover had been partly dismantled by could care for in your district hospital. They debated whether he should go 800 km to the capital, but the limp wrist cannot go home unaided, they may be unable to send him decided them. He started on the long journey with a pack of food, a few there because they cannot contact the rural relatives. He had no longwinded, so you may not get proper feedback unless you appointment, and the surgeon to whom the note was addressed had held the clinic on the previous day. The harassed sister, busy with another clinic, yourself enquire: that is why direct contact is so useful! But there was a three months waiting list, so he had to wait 8days, function, and life-saving surgery is not deferred till after a even for operation as a semi-emergency. Another purpose is to hospital staphylococci, as they began to colonize the skin of this provincial train cadres (not necessarily doctors) to acquire special skills patient. His radial nerve was freed from compression in its spiral groove, and the to deliver surgical services relevant to situations. A friend paid for nearly 4wks in The chances of being able to refer a patient vary greatly, a teaching hospital, and 1600km in transport. They depend on the answers to these were hungry, but he did not have to sell the boat, or the remains of the Land questions: Rover. He could manipulate fractures, but he thought that an expert would hip needing hip replacement)? He was able to reach the next fracture clinic in time, only to find that the till a later date? So he hung around hopefully for some (3) Does he have a condition which will kill him before he days, but in the end he was advised to return to the original hospital. When he eventually returned to the doctor who first saw him, the fracture had partly united in a very bad position. It was now too late to manipulate (4) Will he be able to get there and look after himself when him, so he now has a stiff painful ankle and is waiting to have it fused. Make sure you know the specialists timetable, and his He was still able to walk, so he eventually reached a district hospital, where contact details including mobile phone numbers. You can the wound was carefully toileted, and left open for delayed primary suture. The the voice; with newer mobile phones, you can send pictures wound being clean, it was closed. It was decided to refer him to the provincial hospital 40 km away, across a Beware, though, of possible leaks of confidentiality. There was no radio, and the telephone was not working, so there was no Can the patient get himself to the referral centre? He was able to get a seat on a barge and was in the provincial capital 24hrs later. It was dark districts, for example, the roads and airstrips are closed for but he was able to find a relative with whom he could stay the night. Although learning something from a book is not for many as If he does arrive, will he arrive on the right day, find the way good as learning it first hand from a good teacher, the very to the right clinic, wait in the right queue and be seen and raison dtre of this text is to provide relevant information in admitted? These books, send him to actually be there when he arrives, or will he though, are of no use if they are kept unused on the have gone on holiday, or to a conference in America? Investigate him first if you can, and state the procedure that you think he needs. If a biopsy is necessary, do it, and refer As books are expensive, we have endeavoured to make this him with the report. Often this takes time to obtain or text available electronically as a compact disc, and on the may have to be sent to the referral hospital anyway. If referral is urgent, do not wait for the report, but give sufficient details so the report can be traced. It has not always been easy to distinguish the tasks which are obviously impossible for you (oesophageal atresia for Inform the surgeon that the patient is coming. Make sure that example), from those which may be possible (duodenal or the patient knows exactly what to do, and where to go when jejunoileal atresia). If there are any particularly good referral facilities, such as We have tried to grade the difficulty of operations described. If you can refer the more difficult cases and the patient is likely to obtain a better Finally, do not refer patients unnecessarily. We have stressed, though, that some operations are only for the careful, caring operator. Detail, especially in surgery is important, but you can get Although the common conditions may comprise perhaps bogged down in details. The quotation, Le bon Dieu est 60% of your work, the rest will include many rarer ones.