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A. Zuben. Medaille College.

These figures are for the best hospitals in developed countries buy cheap citalopram 20mg on line, but babies born prematurely in remote areas will have a far lower survival rate discount 20 mg citalopram visa. The smaller the baby, the greater the problems, and the more intensive the care required from specialised units in major hospitals. Tubes and leads to and from the infant may appear to overwhelm it but are necessary to monitor the heart and breathing, supply oxygen, assist breathing in some cases, feed the baby, drain away urine, keep the temperature at the correct level, and maintain the correct chemical balance in the blood. Many require oxygen to allow them to breathe, but too much oxygen can cause a condition called retrolental fibroplasia that damages the retina (light sensitive area) at the back of the eye to cause permanent blindness. Premature babies also progress better if their intensive care nursery is darkened and quietened for the twelve night hours. A baby born prematurely will be a little later in reaching the milestones of infancy and should have routine immunisations in the first six months slightly delayed. The delay is halved by the time the child reaches six months of age, and disappears completely by one year of age. It is rare for an infant born before 24 weeks to survive, and only after 30 weeks are the chances of survival considered to be good. There is no apparent cause in over half the cases, but in others, high blood pressure, diabetes, two or more babies, more than six previous pregnancies, foetal abnormalities, polyhydramnios and abnormalities of the uterus may be responsible. Premature labour may now be prevented or controlled in some cases by injections of drugs such as atobisan, ritodrine (Yutopar) or salbutamol (Ventolin, which is also used to treat asthma). Usually this is the back of the head (occiput), but it may be the buttocks (breech), front of the head (brow) or face. The presentation of the baby during labour is very important, as it will determine the ease of labour and its complications. This is a medical emergency, as the start of labour usually follows soon after the waters break, and the cord will be compressed as the baby moves down into the birth canal, cutting off its oxygen supply. This problem is more common with breech births, as the smaller bottom is more likely than the larger head to allow the cord to slip past it into the birth canal. In the meantime, the mother may be placed in a kneeling position, with her head down on the bed and her bottom in the air. An understandable mistake due to abnormal or missed menstrual periods which lead a woman to be misled into believing she is in early pregnancy is not normally described as a pseudocyesis. Only when a woman does not accept a rational medical explanation that she is not pregnant is the term commonly used. An injection of a local anaesthetic such as lignocaine is given through the lower part of the vagina into the wall of the pelvis around the pudendal nerves that supply the perineum. In men, they are responsible for the enlargement of the penis and scrotum at puberty, the development of facial hair and the ability to produce sperm and ejaculate. In women, the sex hormones that are produced for the first time at puberty cause breast enlargement, hair growth in the armpit and groin, ovulation, the start of menstrual periods, and later act to maintain a pregnancy. During the transition from normal sex hormone production to no production in the menopause, there may be some irregular or inappropriate release of these hormones, causing the symptoms commonly associated with menopause such as irregular periods, irritability and hot flushes. After the menopause, the breasts sag, pubic and armpit hair becomes scanty, and the periods cease due to the lack of sex hormones. Men also go through a form of menopause, the andropause, but more gradually and at a later age, so the effects are far less obvious than in the female. Sex hormones, and many synthesised drugs that act artificially as sex hormones, are used in medicine in two main areas - to correct natural deficiencies in sex hormone production; and to alter the balance between the two female hormones (oestrogen and progestogen) that cause ovulation, to prevent ovulation, and therefore act as a contraceptive. Women who have both their ovaries removed surgically at a time before their natural menopause, will also require sex hormones to be given regularly by mouth, patch or implant. Female sex hormones can also be used to control some forms of recurrent miscarriage and prolong a pregnancy until a baby is mature enough to deliver, to control a disease called endometriosis, and to treat certain types of cancer. The female sex hormone oestrogen can be given as a tablet, patch, vaginal or skin cream, implantable capsule that is placed under the skin or as an injection. If the woman has not had a hysterectomy, she will need to take progestogen as a pill or patch in a cyclical manner every month or two. This may result in a bleed similar to that of a natural menstrual period (but usually much lighter), but gives the added benefit of protecting the woman against uterine cancer. The common sex hormones fall into the categories of oestrogens, progestogens and androgens (male sex hormones). They are used in contraceptive pills, for hormone replacement therapy during and after the menopause, and are usually combined with a progestogen unless the woman has had a hysterectomy. Side effects may include abnormal menstrual bleeding, vaginal thrush, nausea, fluid retention, breast tenderness, bloating and skin pigmentation. They should not be used in pregnancy, breastfeeding, children, and patients with liver diseases or a bad history of blood clots. They are used to control abnormal menstrual bleeds, endometriosis, for preventive contraception, “morning-after” contraception, hormone replacement therapy and premenstrual tension. Medroxyprogesterone is an injectable progesterone that may be used for contraception, to treat certain types of cancer and endometriosis. Side effects include the cessation of menstrual periods, breakthrough vaginal bleeding, headaches, and possibly a prolonged contraceptive action (up to 15 months).

The following are examples of control measures against diseases with various reservoirs: Domestic animals as reservoir: Immunization citalopram 10 mg generic. This is not suitable in the control of diseases in which a large proportion are inapparent infection (without signs and symptoms) or in which maximal infectivity precedes overt illness cheap citalopram 10 mg with amex. Quarantine- is the limitation of freedom of movement of apparently healthy persons or animals who have been exposed to a case of infectious disease. Cholera, Plague, and yellow fever are the three internationally quarantinable diseases by international agreement. Now quarantine is replaced in some countries by active surveillance of the individuals; maintaining close supervision over possible contacts of ill persons to detect infection or illness promptly; their freedom of movement is not restricted. Measures that interrupt the transmission of organisms Action to prevent transmission of disease by ingestion: i. Example vaccination for meningitis Chemoprophylaxis: for example, use of chloroquine to persons traveling to malaria endemic areas. After the epidemic is controlled, strict follow up mechanisms should be designed so as to prevent similar epidemics in the future. Report of the investigation At the end prepare a comprehensive report and submit to the appropriate/concerned bodies like the Woreda Health Office. The report should follow the usual scientific format: introduction, methods, results, discussion, and recommendations. Passive surveillance Passive surveillance may be defined as a mechanism for routine surveillance based on passive case detection and on the routine recording and reporting system. The information provider comes to the health institutions for help, be it medical or other preventive and promotive health services. Advantages of passive surveillance covers a wide range of problems does not require special arrangement it is relatively cheap 69 covers a wider area The disadvantages of passive surveillance The information generated is to a large extent unreliable, incomplete and inaccurate Most of the time, data from passive surveillance is not available on time Most of the time, you may not get the kind of information you desire It lacks representativeness of the whole population since passive surveillance is mainly based on health institution reports Active surveillance Active surveillance is defined as a method of data collection usually on a specific disease, for relatively limited period of time. It involves collection of data from communities such as in house-to-house surveys or mobilizing communities to some central point where data can be collected. This can be arranged by assigning health personnel to collect information on presence or absence of new cases of a particular disease at regular intervals. Example: investigation of out-breaks 70 The advantages of active surveillance the collected data is complete and accurate information collected is timely. The disadvantages of active surveillance it requires good organization, it is expensive it requires skilled human power it is for short period of time(not a continuous process) it is directed towards specific disease conditions Conditions in which active surveillance is appropriate Active surveillance has limited scope. These conditions are: For periodic evaluation of an ongoing program For programs with limited time of operation such as eradication program 71 In unusual situations such as: New disease discovery New mode of transmission When a disease is found to affect a new subgroup of the population. In this strategy several activities from the different vertical programs are coordinated and streamlined in order to make best use of scarce resources. The activities are combined taking advantage of similar surveillance functions, skills, resources, and target population. Integrated disease surveillance strategy recommends coordination and integration of surveillance activities for diseases of public health importance. Diseases included in the integrated disease surveillance system Among the most prevalent health problems 21 (twenty one) communicable diseases and conditions are selected for integrated disease surveillance to be implemented in Ethiopia. Epidemic-Prone Diseases 74 Cholera Diarrhea with blood (Shigella) Yellow fever Measles Meningitis Plague Viral hemorrhagic fevers*** Typhoid fever Relapsing fever Epidemic typhus Malaria B. Principles and Practice of Public Health Surveillance, second edition, Oxford University Press, Oxford, 2000. They are intended to provide the clinician, especially trainees, easy access to basic information needed in day-to-day decision-making and care. Grade A One (or more) mucosal breaks no longer than 5 mm that do not extend between the tops of two mucosal folds. Grade B One (or more) mucosal breaks more than 5 mm long that do not extend between the tops of two mucosal folds. Grade C One (or more) mucosal breaks that are continuous between the tops of two or more mucosal folds but involve <75% of the esophageal circumference. All newly diagnosed cirrhotics and all other cirrhotics who are medically stable, willing to be treated prophylactically, and would benefit from medical or endoscopic therapies. Secondary prophylaxis -Beta-blockers: Meta-analyses suggest that the risk of bleeding is decreased by 40%, the risk of death by 20%. Inject air through the gastric suction port and auscultate over the stomach (for presumptive evident that the tube has been properly inserted). Use of a pulley-weight system traction on the tube is discouraged because if the gastric balloon should deflate, the esophageal balloon (if inflated) could be pulled up and obstruct the airway. Monitor the pressure in the esophageal balloon by attaching its port to a sphygmomanometer; check pressure every 30-60 minutes.

Sedation is seldom needed but citalopram 40mg without a prescription, if used safe citalopram 10 mg, suggested discharge crite- ria should be met and the patient must receive an appropriate explanation. Oral analgesics should be started before the local anaesthesia begins to wear off and also given subsequently on a regular basis. On completion of training they are not qualified to undertake regional anaesthesia or regional blocks. Postoperative recovery and discharge Recovery from anaesthesia and surgery can be divided into three phases: 1 First stage recovery lasts until the patient is awake, protective reflexes have returned and pain is controlled. This should be undertaken in a recovery area with appropriate facilities and staffing. Use of modern drugs and techniques may allow early recovery to be complete by the time the patient leaves the operating theatre, allowing some patients to bypass the first stage recovery area. Most patients who undergo surgery with a local anaesthetic block can be fast-tracked in this manner. The anaesthetist and surgeon (or a deputy) must be contactable to help deal with problems. Some of the traditional discharge criteria such as tolerating fluids and passing urine are no longer enforced. Mandatory oral intake is not necessary and may Ó 2011 The Authors Anaesthesia Ó 2011 The Association of Anaesthetists of Great Britain and Ireland 11 Guidelines: Day case and short stay surgery. Voiding is also not always required, although it is important to identify and retain patients who are at particular risk of developing later problems, such as those who have experienced prolonged instrumentation or manipulation of the bladder. Protocols may be adapted to allow low-risk patients to be discharged without fulfilling traditional criteria. This is usually insignificant and should not influence discharge provided social circum- stances permit; in fact, the avoidance of hospitalisation after minor surgery is preferred [15, 44]. Patients and their carers should be provided with written information that includes warning signs of possible complications and where to seek help. Protocols should exist for the management of patients who require unscheduled admission, especially in a stand-alone unit. Postoperative instructions and discharge All patients should receive verbal and written instructions on discharge and be warned of any symptoms that might be experienced. Wherever possible, these instructions should be given in the presence of the responsible person who is to escort and care for the patient at home. Advice should be given not to drink alcohol, operate machinery or drive for 24 h after a general anaesthetic. More importantly, patients should not drive until the pain or immobility from their operation allows them to control their car safely and perform an emergency stop. All patients should be discharged with a supply of appropriate analgesics and instructions in their use. Analgesia protocols (Appendix 4) relating to day surgery case mix should be agreed with the pharmacy. Free pre-packaged take-home medications should be provided as they are convenient and prevent delays and unnecessary visits to the hospital pharmacy. Discharge summary It is essential to inform the patient’s general practitioner promptly of the type of anaesthetic given, the surgical procedure performed and Ó 2011 The Authors 12 Anaesthesia Ó 2011 The Association of Anaesthetists of Great Britain and Ireland Guidelines: Day case and short stay surgery. Patients should be given a copy of this discharge summary to have available should they require medical assistance overnight. Day surgery units must agree with their local primary care teams how support is to be provided for patients in the event of postoperative problems. Best practice is a helpline for the first 24 h after discharge and to telephone the patient the next day. Telephone follow-up is highly rated by patients, provides support for any immediate compli- cations, and is useful for auditing postoperative symptoms and patient satisfaction. Audit Effective audit is an essential component of assessing, monitoring and maintaining the efficiency and quality of patient care in day surgery units. Systems should be in place to ensure the routine collection of data regarding patient throughput and outcomes. Questionnaires, which rely on the patients’ completing documentation and returning them to the day unit, are notoriously inaccurate and response rates are often very low. The most successful units collect data electronically at all stages of the day surgery process. It must be stressed that the most reliable way of improving service is continuous audit and review of outcomes rather than one-off snapshots. Information regarding trends in the patients’ outcomes should be widely distributed amongst the members of the team. Examples of day surgery processes amenable to audit that have some measurable outcomes are shown in Table 2. A robust database is helpful; however, the best databases fail to effect change unless the information is clearly displayed and freely disseminated to the day surgery users. Monthly graphs and figures detailing all outcomes and trends should be disseminated to everyone, particularly to key individuals empowered to influence change. However, formal day surgery training programmes for anaesthetic (and surgical) trainees are rare.

Dermatophytes in skin scales: look for branching septate hyphae with angular or spherical arthrospores generic citalopram 10 mg, usually in chains order 10 mg citalopram visa. All species of ringworm fungi have a similar appearance Fungi need to be distinguished from epidermal cell outlines, elastic fibers, and artifacts such as intracellular cholesterol (mosaic fungus) and strands of cotton or vegetable fibers. Ringworm fungal hyphae can be differentiated from these structures by their branching, uniform width, and cross- walls (septa), which can be seen when using 40-x objective. In Superficial Candidiasis, the fungus may be seen as budding yeast cells and in the majority of instances mycelium is also present. Right: Gram stain preparation of skin scales preparation showing gram positive as seen with the 40x objective C albicans yeasts and psuedohyphe 5. Wood’s light can be used to assist clinical diagnosis and to select suitable scalp material for laboratory investigation. Care must be taken to differentiate between true fungal fluorescence (bright green) and 121 the auto fluorescence of keratin (dull blue) or the fluorescence of creams and ointments that may have been applied to the lesion. It is clear that a primary infection produces partial local immunity to reinfection but this protection varies in duration and extent depending on the host, the site of infection and the species of Dermatophytes. Cutaneous hypersensitivity (immediate and/or delayed) may occur and circulating antibodies have been detected in infected individuals but neither phenomenon has been shown to be of any diagnostic value. Although many dermatophytes may develop recognizable colonies 0 with in 5-7 days, cultures should be retained for at least 3 weeks at 25-30 C and longer at lower temperatures before making a final diagnosis. Either Petri dish or test tube culture is satisfactory and there is little risk of laboratory infection. Dermatophyte isolates can usually be distinguished from contaminants by the occurrence of compact growth around the inocula and the color of the colony Dermatophytes are never green, blue or black. Cell culture – cytopathic effect, hemadsorption, confirmation by neutralization, interference, immunofluorescence etc. Serology; detection of antibody and convalescent stages of infection, or the detection of IgM in primary infection. Direct examination of specimen o Fluoresce in an enzyme or a radiolabel (the indicator system) is conjugated to the antibody used to detect the virus (Primary antibody) specifically. A common application of antigen capture, for which several commercial kits are available, is in the diagnosis of Herpes simplex. For rapid diagnostic purposes, virus-specific nucleic acid sequences in serum, cells or tissue extracts are detected primarily by dot- blot hybridization techniques. It is extremely sensitive and widely regarded as a research tool with limited application to the diagnostic workbench. Indirect examination o The indicator system is conjugated to a secondary antibody, which in turn directed against the primary antibody. Serologic Methods – detection of rising titers of antibody between acute & convalescent stages of infection Measurement of IgG antiviral antibodies is used to determine immunity, while quantization of IgG or IgM antibodies can diagnose current or recent infection. Laboratory Diagnosis of Cutaneous Leishmaniasis - Cutaneous leishmaniasis in Ethiopia is caused by the following Leishmania species: L. Collection and examination of slit skin smears for amastigotes Material for examination should be taken from the inflamed raised swollen edge of an ulcer or nodule. Its base or center, which usually contains only necrotic tissue should be taken to avoided because it can contaminate the specimen with blood and is low yield for amastigotes. Note: Secondary bacterial contamination makes it difficult to find parasites and therefore if bacterial infection is present, delay examination for leishmania amastigotes until antimicrobial treatment has been completed and the bacterial infection has cleared. Firmly squeeze the edge of the lesion between the finger and thumb to drain the area of blood (protective rubber glove should be worn) 3. Spread the material on a clean slide using a circular motion and working outwards to avoid damaging parasites in those parts of the smear that have started to dry. When dry, fix the smear by covering it with a few drops of absolute methanol – Fix for 2-3 minutes and stain the smear using the Giemsa technique. This solution requires minutes staining time; Preparation of 10% solution: Measure 45 ml of buffered water Ph 7. Place the slides in a shallow tray, supported on two rods, in a coplin jar, or in a staining rack for immersion in a staining trough C. C Pour the diluted stain into the shallow tray, Coplin jar, or stain thoroughly and stain for 10 minutes D. When the smear is dry, spread a drop of immersion oil on it and examine first with the 10 x and 40 x objectives to detect macrophages which may contain amastigotes (the parasites can also be found outside macrophages) use the 100-X oil immersion objective to identify the amastigotes. Morphological characteristic of amastigotes - Amastigotes are – small round to oval bodies measuring 2-4 μm 127 • Can be seen in groups inside blood monocycles (less commonly in neutrophils), in macrophages in aspirates or skin smears, or lying free between cells • The nucleus and rod-shaped kinetoplast in each amastigotes stain dark reddish mauve • The cytoplasm stains pale and is often difficult to see when amastigotes are clustered in a group. Serological diagnosis of cutaneous leshmaniasis Because of the poor antibody response in continuous leishmaniasis serological tests are of little value in diagnosis. Leishmanin test The antigen used in the leishmanin test (or Montenegro reaction), is prepared from 6 killed culture promastigotes of L. Positive reaction: The reaction is considered positive when the area of indurations is 5mm in diameter or more.