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By M. Reto. Smith College.

As already mentioned cheap 5 mg nebivolol with amex, mothers are increasingly delivering their first child at older ages buy nebivolol 2.5 mg on line. Maternal and fetal problems are well known: increased incidence of dystocic deliveries (e. More difficult to evaluate in all its extension is the morbidity linked to an unpleasant sexual life. Sexual and reproductive health is an important measure of the general health and social well being of a population. Moreover, the scope of sexual and reproductive health extends across the life span (from adolescence to the ageing) and across several Public Health domains. In order that sound evidence based politics can be taken on these issues, some more evidence based knowledge and wisdom is needed, overcoming existing ignorance and misconceptions. This can be done with small adaptations and will be a reliable approach to teenagers specific needs and autonomy. Monitoring reproductive health in Europe what are the best indicators of reproductive health? Factors associated with teenage pregnancy in the European Union countries: a systematic review. Special issue of European Journal of Obstetrics & Gynecology and Reproductive Biology 111 Suppl 1:S5- S14, 2003. Gissler M, Dumitrescu A, Addor V: Improving the performance of National Health Information Systems: the 2002-2003 reform in Finland from an international perspective. Monitoring health in Europe: opportunities, challenges, and progress Eur J Public Health 13 (supplement 3): 1-4, 2003. The generic term for such indicators is health expectancies and they are summary measures of population health combining information on survival with the prevalence of a health measure (Robine 2006). The most common health measure used is disability, producing disability-free life expectancy. Background to health expectancies Research on health expectancies dates back to the 1960s. Being independent of the size of populations and of their age structure, health expectancies allow direct comparison of the different groups that make up populations: e. Since that time health expectancies have been increasingly used in developed countries to assess the evolution of a populations health status, in particular that of older people (Robine et al. However comparison between countries remained almost impossible due to national differences in the morbidity data collected, particularly in the study design, the health concepts used and the wording of questions. In total 10 instruments were proposed with their exact wording in English (Box 1). The set allows in theory the computation of many health expectancies covering the totality of the conceptual framework of the measurement of population health. Similar methodology was used in the development of the 10 health indicators: a systematic review of the literature on the concept and wording of questions and their previous use in surveys. Do you suffer from (have) any chronic (long-standing) illness or condition (health problem)? For the past 6 months or more have you been limited in activities people usually do because of a health problem? Ultimately 9 indicators were chosen: chronic morbidity (global and detailed); activity limitation (global); perceived health (global); physical and sensory functional limitations; personal care activities; household care activities; other activities; and mental health. Indeed it is crucial that even if existing 293 items are taken from current European Surveys, existing translations are not automatically taken but that new translations following a standard scientific protocol are undertaken. However 2003-2004 was a transitional period, during which data were provided by national sources with post- harmonisation giving a break in series. Considerable disparities are evident between the European Member States in the level of chronic morbidity reported by the population. The reported prevalence in women is higher than that for men within every Member State though the gender gap varies from 2. However men and women give the same picture of the diversity of chronic health problems reported in Europe. Briefly this entails applying the age and gender specific prevalence of chronic morbidity, presented in the previous section, to the life table for the corresponding years of the survey from which the prevalence data were obtained. The gender gap in life expectancy at age 65 within Member States in 2005 was only 2. There appeared to be little relationship between the increase over the period 1995 -2005 and life expectancy at age 65 in 1995 for either men or women. Thus there was no evidence that Member States with the highest life expectancies at the beginning of the period were showing signs of reaching a maximum value. On average increases in the later period were marginally greater than those in the early period. Increases in the two periods remained constant in Austria, Portugal, Sweden and United Kingdom in men and Austria in women.

Destruction of their is poor T-cell immunity and the presence of nodules & sensory fibres makes the surface of the body anaesthetic buy nebivolol 2.5 mg with visa, plaques order nebivolol 2.5 mg line. This involvement can be slow, progressive, and and thus liable to injuries that result in open wounds and irreversible, or can occur suddenly in a Type I reaction. Destruction of their motor fibres causes paralysis, wasting, and sometimes contractures of the muscles. This results in neglect of the (2) the ulnar nerve at the elbow or wrist, so that the hand painless surface injuries, so that they become becomes clawed. The contractures, ulcers, (3) the median nerve at the wrist, so that the thumb cannot and deformities that result are not an inevitable part of be opposed. If your staff behave naturally towards them, Both kinds of lepra reaction can cause paralysis, other patients will do so too. Leprosy is not contagious and but need different management: not particularly infectious. They may be Turn the blade through 90 and scrape the skin, putting painless, or tender. Skin lesions may ulcerate, and tissue on a slide and staining it by the Ziehl-Neelsen resulting fibrosis may lead to contracture, unless you start method. Bacilli reach the joints thickened, especially over the backs of the hands and on usually from some focus elsewhere. Unfortunately, The patient is usually a young adult, or a child >6yrs, they are less likely to recover than after a Type I reaction. One or more reaction with prednisolone 60mg od, reduced rapidly of the joints has become progressively painful and stiff within 2-4wks. If the leg is involved, the Use thalidomide 10mg/kg for recurrent reactions, reducing first complaint is a limp. The infected joint fills with fluid, to 100mg od (but remember this drug is teratogenic! There is usually only mild Use clofazimine 300mg od for maintenance once the acute to moderate pain, except on forced movement. Sometimes there are systemic symptoms, such as not improve for 3 months, or a year, or longer. As long as there are signs of weakness, someone, underlying bone, which decalcifies. In the spine, disease or preferably the patient himself, must put all the paralysed starts in a disc. If you start treatment before the cartilage is joints through their full range of movement each day, destroyed, the joint will recover fully, or nearly so. If you even if they cannot be actively maintained in their start later, the articular cartilage will be destroyed, so that positions of function. Make sure active exercises considerable distance to produce a sinus far from the continue in order to retain mobility in all the joints. If a tuberculous joint is secondarily Even if all the intrinsic muscles of the hand are paralysed, infected, the ankylosis that results is always bony. Start this protection the first day you joints may subluxate or dislocate, especially the hip, knee, diagnose a reaction. You can treat tuberculous joints successfully and cheaply; When there are signs of recovery, as shown by pain if you make the diagnose in the first few weeks. If it is already involved when you first see the Even so, your error rate is likely to be small. Suggesting other forms of arthritis: a history of This will overcome spasm, prevent the softened bone from dysentery, brucellosis, or gonorrhoea. Use the anterolateral completed, warn that the joint may flare up again at any approach, as for septic arthritis (7. The range of movement of distinguishing tuberculosis from late, imperfectly-treated the joint may be limited or absent, so make sure that it is staphylococcal arthritis. If the leg moves into external rotation, as you do this, (7-17), it is a sign that the upper femoral epiphysis is slipping. He dragged himself along in arthritis (or spontaneous slipping of the epiphysis, a sitting position, with both knees and hips fully flexed. If a child requires an arthrodesis of the knee, Rest the arm in a sling, and then gradually encourage try to delay this until after adolescence, so as not to hinder movements without it. An elbow fixed in the position of function sheaths of the hand, or bursae round the shoulder develop, (7-16), is likely to be better than a stiff painful one. In children presenting with a painful hip or a limp (1),Wait 4-6wks, before committing yourself to long-term (32. This will control pain If deformity prevents satisfactory walking, and prevent a flexion contracture. If pain and inflammation continue, and there is no Skin traction should have corrected any flexion contracture bony injury and no ligament rupture, start another full (if present) by this time.

Take care if there has been a previous Caesarean peritoneum over the uterus purchase nebivolol 2.5 mg amex, just below the point where the Section (21 nebivolol 5 mg free shipping. Then tear the peritoneum with your fingers to left and right, If necessary, extend the skin incision further down. If you use a Pfannenstiel incision, use your fingers aim your fingers in a more cephalic direction, so that the tear in a similar way for the tissues under the skin and above the in the peritoneum is curved (21-12J). Try to leave a bare fascia, even the fascia and also, now directed vertically, area about 2cm wide and 12cm long. Use two haemostats to pick up (2) Do not denude the lower segment for >5cm: if the cervix peritoneum near the upper end of the incision (21-12E). Meconium is irritant, longitudinally from above downwards to just above the and if it becomes infected peritonitis may follow. If you cut the bowel by mistake, Make a superficial incision over the full trajectory of the clamp it and close it later (11-5). This should be Clamp any active bleeding vessels if they are big, 2cm below the peritoneal reflection, and at least but postpone tying them until later in order to save time. They usually stop bleeding on their own anyway, although Do not make your transverse incision too low in the lower this does not always happen if you use a Pfannenstiel segment. Then go somewhat deeper in the midline because the current may cause foetal cardiac dysrhythmias. Do not try to aspirate the nose especially fingers bleed less and the extent of the opening is easy to with a big Yankauer sucker: it may push maternal blood into control. A major advantage is that you cannot in this way cut the nose and/or traumatise the nasal passages. Ergometrine occasionally makes a conscious patient sick, and may raise the blood pressure. Protect it with a finger will often not notice relaxation because bleeding will not be between the membranes and the uterine wall if you use overt. An oxytocin infusion at the end of the operation and scissors instead of tearing with your fingers. Also, when you because blood loss from the injured sinuses of the placenta suture it, you will be less likely to suture the ureters. If you can feel the foetal vertex through the uterine wall, Now deliver the uterus by lifting the fundus out of the the placenta is probably lying in the fundus or posteriorly, abdomen; it is easier then to see what you are doing. If you are a quick operator, apply one Green-Armytage If you tear the placenta as you open the uterus, try to clamp (or sponge-holding forceps) at one angle of the detach it, and deliver the foetus around it. There can be severe bleeding from a lacerated placenta, so clamp the umbilical cord If you are a slow operator, apply several Green-Armytage quickly (21. Do not pull on the clamps during suturing as this will result in an asymmetric If there are large veins over the lower segment, closure. The veins will probably stop bleeding soon by a combination of controlled cord traction and fundal after. If necessary, help it to contract by massaging the fundus from inside the abdomen. If there is a placenta praevia grown into a previous Then put your hand outside the lower flap of the incision, Caesarean Section scar, there is serious danger of serious and lift the foetal head up (21-12P). If you cannot remove the placenta manually (the practical If the incision is not long enough to deliver the foetus definition of placenta accreta) then you may be forced to without a lateral tear, extend its ends upwards and laterally proceed to hysterectomy. Do not probe the cervix to improve drainage: on them: they tend to slip off or break and are costly! Do not use non- cleaner if you have previously inserted abdominal packs absorbable sutures, particularly not on the inner wall. Wash out the abdominal cavity Ask your assistant to hold the lower edge of the uterus with copious warm water if there was soiling present. Start the first sutures just beyond the lateral greater omentum over the uterus: it will usually reach the extremity of the wound. Then re-start with the first suture and contact is important in developing the bond between them. Estimate the blood loss: it will probably be more than you Unless the sutures are tight, they will not stop the bleeding. So, before the first layer of sutures is completed, theatre in reasonable condition is now collapsed. Suture only the uterus, and not too deeply downwards towards the vault of the vagina. If you are in any If the membranes were ruptured for >24hrs before the doubt, put your fingers down behind the uterus before you operation, or there are other reasons for suspecting start to close the lateral extremities of the opening so that the infection, continue antibiotics for 3days. When the uterus is no longer bleeding, close the peritoneum of the vesico-uterine pouch with continuous sutures of If vomiting ensues with abdominal distension, non-absorbable (21-12V). Do not close the peritoneum until you have or add these details to the babys birth card.

Put a moist pack over the colon and draw it towards you buy nebivolol 5 mg with amex, so as to stretch the peritoneum in the right paracolic gutter order 5mg nebivolol mastercard. As you incise the peritoneum, draw the entire colon medially, from the caecum to the hepatic flexure. The danger is that death from peritonitis may ensue if you fail to remove all non-viable bowel. If there is a gangrenous intussusceptum protruding from the anus, tie it off tightly and amputate it before opening the abdomen. You will then be able to reduce the remaining intussuscepted bowel easily from inside, and Fig. Do not resect Yearbook Medical 1979 Fig 93-3 with kind permission terminal ileum and leave an anastomosis within 5cm of the caecum. Use the gauze to transmit the pressure to as wide As you lift the caecum and ascending colon medially, you an area of the bowel as you can. Be patient, and change the Hold up the colon and try to see them against the light. Make windows in the peritoneum on the medial side of the The intussusception will usually reduce itself quickly. Then tie the vessels held in each haemostat with 2/0 or 3/0 (2) you cannot reduce the intussusception any further. Cut between them and the colon, until it is (2);Make sure that there is no tension on the ileum or completely free. Apply haemostats to the mesentery of the ileum 2cm from the bowel, and cut between them until you reach healthy Manage the ileostomy by fitting a standard drainable bowel supplied by a visibly pulsating vessel. Protect the skin with greater omentum towards the head, and use scissors to zinc oxide cream, barrier cream, or karya gum powder. If the effluent is copious and very liquid, nurse the patient in a prone position with Mobilize the hepatic flexure under direct vision. As you lift it up, make sure that end-to-end anastomosis preferably with one layer of there is healthy bowel above skin level at both ends. If a distal colo-colic intussusception requires resection, Do this in the same way as for the opposite side, but take perform a Hartmanns operation (12. By drawing a knife The small bowel spontaneously rotates on its mesentery, along the crushing bowel clamps (on the side where the or on a band 5-10cm from the ileo-caecal valve, which non-crushing clamps are), amputate the non-viable bowel. As it rotates it Decompress the bowel contents from the proximal end by traps large volumes of blood and fluid. Most of the small suction or by drainage into a bowl after packing away the bowel may rotate, apart from its top and bottom ends, abdomen. You now have the choice of either exteriorizing the bowel Sometimes, an adhesion to a loop of small bowel starts the or doing an anastomosis. By doing this, you may avoid contaminating the small bowel may twist around this (12-14) producing the peritoneal cavity and improve the chances of survival. When you have done this, the patient will find himself with a temporary ileostomy and colostomy, but you will Volvulus of the small bowel is a sudden deadly illness in have saved his life. A typical history is of sudden abdominal colic, distension Examine the proximal and distal ends of the strangulated and vomiting, coming on after a large evening meal. Early on, the patient does not look particularly ill although Protect the area with carefully applied towels. One of If you have difficulty untwisting the bowel, decompress your difficulties will be to make the diagnosis, when all it first. Introduce the suction nozzle into a distended loop you see at laparotomy are distended loops of small bowel. Do this routinely if the bowel is Manipulating distended bowel is dangerous, whether or obviously non-viable. If a loop ruptures, survival is in doubt because of septic flooding of the peritoneal cavity If the bowel is viable, decompress it by massaging the that results. If the bowel is not viable, and the gangrenous section ends well proximal to the ileo-caecal valve, resect it and perform an end-to-end ileal anastomosis after decompressing the bowel (11. If the bowel is gangrenous down to the caecum, perform an ileocaecal resection (12. Be sure to select healthy bowel for the anastomosis, with obviously visible pulsations in the vessels that supply it: a serious and sometimes fatal Fig. When a strangulated closed loop is distended with blood, there may be no fluid levels, A long sigmoid colon distended with the gas of a high- so that the radiographs appear normal. A collapsed caecum shows that the obstruction is in colon becomes gangrenous and may perforate. Sigmoid volvulus is however less dangerous and more common than small bowel volvulus (12. Approach this by first putting your hand down into the pelvis, and then up In a patient, normally male, with his first episode of along the posterior border of the abdominal wall. However, usually there have been many first few centimetres of the jejunum and the terminal undiagnosed episodes of volvulus; the long mesentery is ileum. Take great care younger adults, the small bowel is pulled round with the doing this so you do not inadvertently puncture the bowel sigmoid and an ileosigmoid knot (compound sigmoid and spill large volumes of bowel contents!