It is worn for three weeks The Population Council cheap kamagra super express erectile dysfunction drugs prostate cancer, New York has developed an implant known as Norplant (consisting of six tiny silicone of the cycle purchase kamagra super with visa erectile dysfunction 45 year old male. Among typical couples taken after unprotected sex to prevent pregnancy from who use female condoms proven kamagra super 160mg diabetes and erectile dysfunction health, 21 percent will experience occurring. If the condoms are used consistently and correctly, about 5 percent will 21,24 become pregnant. The advantages and disadvantages Types of Emergency Contraception are given below:23 Several types of emergency contraception drugs are available. Advantages Levonorgestrel: The progestin-only method uses the • Give women more control and a sense of freedom. Combined or Yuzpe regimen: This uses large doses of • Polyurethane transmits heat well and this may make both estrogen and progestin, taken as two doses at a sex more fun. It is possible to obtain the same dosage • The condom can be safely used if either partner is of hormones, and therefore the same effect, by taking allergic to latex. This method is now believed to be less Disadvantages effective and less well-tolerated than the progestin-only • It is large, unattractive or odd looking. Ulipristal acetate: This drug is similar to mifepristone, was approved in early 2009. They are only for emergencies, and should be used up to 5 days after unprotected intercourse, the not be used as a routine birth control method, because terms like ‘morning-after’ or ‘post-coital’ pills do not convey the correct timing of use. The only 615 it is actually less effective at preventing pregnancies than most types of birth control. It is are informed in advance about the option of using primarily because they will not be effective. Since it acts before implantation, they are considered as Safety contraceptive pills. There is no medical condition for which the risks of emergency contraceptive pills outweigh the benefits. M echanism of Action Emergency contraceptives work mostly by preventing Postconceptional Methods or delaying ovulation-the same way that taking regular birth control pills works. Yuzpe and Menstrual regulation is commonly defined as evacuation progestin-only emergency contraception will have no of the uterus in a woman who has missed her menstrual effect if taken after implantation, whereas mifepristone period by 14 days or less, who previously had regular periods and who has been at risk of conception. Menstrual regulation is a relatively studies may find varying rates of effectiveness. Late compli- Levonorgestrel is reported to have an highest effectiveness cations (after 6 weeks) may be infertility (secondary to (89%), compared to the other methods. Since this procedure is levonorgestrel and Yuzpe regimens, the effectiveness of usually carried out without confirmation of pregnancy, emergency contraception is highest when taken within 12 27-30 it is possible that some women may be subjected to it hours of intercourse and declines over time. Secondly, in reference to the first point, there is no legal Side Effects bar to menstrual regulation in many countries because Generally, less than 20 percent women suffer from any there is no proof that the woman is pregnant. Other common side sustained uterine contraction for 7 minutes and cyclic effects were abdominal pain, fatigue, headache, dizziness, contractions for next 3 to 4 hours. Bleeding continues temporary disruption of menstrual cycle and breast for about a week. However, abortion rates are pregnancy include the following: high in many countries irrespective of the fact whether abortion is legal or illegal. The risk of death depends upon the conditions under which abortion is carried out and When there is risk of the child being born with serious by whom. It is an – Smallpox or chickenpox antiprogestin that blocks the effect of progesterone on – Viral hepatitis the lining of the uterus. It is followed by taking a – Toxoplasmosis prostaglandin called misoprostal 48 hours later. A woman must return to the clinic after 48 failure in a married woman, and is likely to cause hours to receive the prostaglandin which will complete grave injury to her mental health. The woman stays at the clinic for the next • When social or economic environment, actual or 4 to 6 hours. Only a qualified registered medical practitioner Incomplete abortion occurs in 2 to 3 percent of cases. The consent of the woman is required before Ru-486 in conjunction with a prostaglandin is 95. If the period of pregnancy is below 12 weeks, ectopic pregnancy or any contraindicators to prostag- it can be terminated on the opinion of a single doctor. In an emergency, preg- clamp, used to make a puncture into the skin overlying nancy can be terminated by a single doctor (even after the fixed vas. After widening of the initial punctured hole 20 weeks) without consulting a second doctor, in a with the vas dissecting clamp, the vas can be seen and private hospital which is not recognized. At the end of the provided he has acted in good faith and exercised procedure, suturing of the wound is not needed, only proper care and skill. Facilities for training and equipment have also standard incisional technique because: (i) it eliminates been made available free of cost for private clinics. The tubes are surgically closed with bands, clips, Vasectomy is a safe permanent method of contraception electrocautery or by cutting and tying. The operation in which the tubes through which sperm travels from the can be performed under local anesthesia on an testes to the penis are cut and blocked so that sper- outpatient basis through a small incision matozoa can no longer enter the semen that is ejaculated. Worldwide The operative procedure is carried out under local anes- it is the most commonly used method of birth control. Blood clots, infection and epididymitis occur therapy; very rarely, such complications may be fatal. The failure rate is 1 to 5 children are desired and should be considered a 11 percent during the first 10 years after the operation. The tubal closure should be performed It was developed in 1974 by Dr Li Shungiang at by surgical ligation, band or clip. Electrocautery should Chongging Family Planning Scientific Research Institute, be avoided because of higher risk of damaging other People’s Republic of China. Another method which has gained wide states that they should ‘have long-lasting protective effect popularity is laparoscopic sterilization using the after a single course of immunization; they would not transabdominal route. This method is used as an cause menstrual-cycle disturbances and other hormone- outpatients procedure and can be performed in a very dependent side effects; they would be easy to administer short time. However, it obviously requires costly by a well-accepted procedure; and they could be manu- equipment in the nature of an endoscope, as well as factured at low unit cost. Three addi- laparoscopic sterilization is inversely proportional to the tional possible advantages were pointed out:44 ‘The ideal training of the surgeon. Vaccines have the advantage of hysteroscopically delivered and requires no incision or being free from risk of user-failure. Once inserted into the fallopian tube, if Unlike conventional methods, contraceptive vaccines expands to fill the instrumental to isthmic section of the use the immune system to induce antibodies against fallopian tube. Although these vaccines can be used both by • No pregnancies occurred during the follow-up men and women, most research is directed towards period. Recipients need synthetic hormone ducted in the 1980’s: under the auspices of the replacement in order to counteract unwanted side effects Population Council in India and Scandinavia, 88 such as loss of bone density. In women, a reaction 619 sterilised women used a prototype based on the whole similar to artificial menopause is induced. It is generally assumed that the final product will be 100 women in the first year), safe and easy to use and an antifertility vaccine administered by injection or orally requires no pelvic examination prior to starting the drug.

Short-term order kamagra super canada erectile dysfunction due to old age, rather than long-term purchase kamagra super paypal erectile dysfunction drugs ayurveda, perspective of a change in the population structure purchase generic kamagra super canada impotence juicing, characterized by 44 development efforts. This, in turn, increases well as too much affluence, lead to environmental national productivity and thus brings about economic degradation and damage to earth’s ecology. Environmental degradation social component of socioeconomic development is no ultimately results in ill-health, due to either malnutrition less important. The mechanisms involved are shown in services may be summarized by saying that they Figure 26. This has been made possible by intensive longevity of life,the third being the literacy rate. As a result, However, quality of life also depends upon the degree groundwater level has dropped by 7 to 10 meters during of happiness and security enjoyed by the people. This is expressed as follows by the Prime used to cultivate sugarcane fields, a cash crop. Three main causes of environmental degradation are identified: Poverty, affluence and short-term policy perspectives. It may be noted that mass poverty forces people to adopt means of economic “development” that result in environmental degradation and are ultimately counter-productive. The high consumption of newsprint simply means high degradation of forests, and must be reduced. There they are broken dimensions like life expectancy, literacy, education and down by sunlight and chlorine atoms are released. As a health and longevity is expressed by life expectancy at result the ozone layer around the earth gets depleted. An ozone hole was discovered for enrolment ratio (with one-third weighting), and the first time in 1947 and such findings have been standard of living, as indicated by the natural logarithm repeatedly reported since then. For policy-makers, the poverty of choices and opportu- Gender Empowerment Measure is calculated by nities is often more relevant than the poverty of income, measuring political and economic participation and for it focuses on the causes of poverty and leads directly control wielded by women in different Indian States. Political participation is calculated by poverty of choices and opportunities implies that poverty taking into consideration the number of women must be addressed in all its dimensions, not income alone. Economic deprivation in the quality of life to arrive at an aggregate participation has been calculated by evaluating the judgment on the extent of poverty in a community. Delhi: Sterling communication and is measured by the percentage of Publishers 1984;20:47. Report of the Health Survey and Development in particular, overall economic provisions. This is repre- sented by a composite of three variables: the percentage Committee. Reprinted in condensed form in Health workers under Health and Family Planning Program. Report of the Group on Medical Education Rural India: The Narangwal Experiment, vol. Such Adam Smith, the father of economics, defined concern broadly relates to: (i) The sources of finance for economics as a science which studies the nature and health services; (ii) The ability to maintain at least the past causes of national wealth. As a matter of fact, he wrote funding levels; (iii) Resource allocation patterns and, the book in 1776, commonly known as the Wealth of (iv) Economic efficiency, with equity, of health service 1 Nations, is titled “An Enquiry into the Nature and Causes delivery, etc. In developed countries, too, with rich economies, the concern about the high costs of health of the Wealth of Nations. Economic concern about the rising cost Marshall considered economics as a means or an of health services formed an important part of the political instrument to better the conditions of life. In this background, it is important for all public business of life; it examines that part of the individual health specialists, specially the health administrators, to and social action which is most closely connected with know and apply the principles of economics in the field the attainment and use of the material requisites of well- of health. This is particularly important scarcity, defines it as “the science which studies human in relation to health planning, management and health behavior as a relationship between ends and scarce care delivery. It is interesting to note that the following questions, to which clearer answers were sought Health Economics at that seminar, are relevant even today: (i) What is a Health economics has been explained by various reasonable price to pay for health? The related curative and rehabilitative health services, so as to definitions are as follows: achieve maximal individual and national productivity. Against a background of increasing demands on securing health services could be viewed in monetary limited health resources, economic evaluation helps as well as nonmonetary terms. When services are decision making by considering the “outputs” of compe- provided by the government, these should not be ting interventions in relation to the resources they con- considered, in strict economic sense, free or without sume. Thus even for availing of the so-called free services, There are four main types of economic analysis in one has to make sacrifice in terms of traveling and health: waiting time and transportation cost, etc. Cost-effectiveness: Here a clinical output such as understand the performance of economy. These indicate morbidity, mortality, reduction in blood pressure or the sum total of three components in a country, namely: quality of life, etc. Cost-effectiveness analysis has generally and services, and (c) investment expenditure. In this Poverty Line context the economist’s notion of scarcity is of special interest. The health needs (whether perceived from the Poverty line is generally defined in terms of minimum per angle of the professional providers or from the point capita consumption level of the people. As per the defi- of view of community needs) are infinite whereas the nition given by the planning commission, this level is the resources are definitely limited, in India as elsewhere. Thus poverty line refers to the For this reason alone, welfare governments everywhere cut off point of income below which people are not able try to ensure that economic thinking is built more closely to purchase food sufficient to provide 2400 kcal per head in the planning and decision making process, keeping per day. This income level has been fixed by the plan- the cardinal concept of scarcity in view. Definitions and methodologies used for estimating poverty line differ Demand from one source to other. According to the sixth five-year It means, in simple terms, the type, quantity and quality plan document, “A family having five members, whose of services or commodities wanted or requested. Mere expressions of health needs and wants do not become demands, or effective demands, Costs can be classified in many ways. In general, costs for health care services unless they are backed or refer to the resources which are spent in carrying out supported by willingness and ability to pay for these health activities so far as the health care sector is con- 525 needs and wants. It is to be understood that “unrealized” or “non- realized” benefits also count towards costs. It is the could be the loss of productivity due to morbidity, dis- total cost of an activity divided by the number of ability or mortality. In general, costs can be classified into two broad • Opportunity cost: This economic concept is quite groups: capital costs and operating (sometimes known important and usually forgotten in costing. In order to compute one possible economic approach for the health the yearly costs of such items as building, manager is to consider: refrigerator, etc. Capital costs are also termed as capital expendi- – What shift of health resources is needed if the ture; capital goods represent capital investment. Opportunity costs operate not from the or type of activity in a health institution.

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This creates a larger endplate potential than that seen with lesser motor neuron activation buy discount kamagra super online fda approved erectile dysfunction drugs. Although this potential proceeds down the muscle fiber with decrement proven 160 mg kamagra super erectile dysfunction treatment dallas texas, the depolarization reaching the first sodium channels is greater than its threshold order 160 mg kamagra super mastercard impotence 27 years old, and the muscle fiber is able to fire an action potential. Action potentials are self- reinforcing and travel down the muscle fiber without decrement in a manner similar to that seen in unmyelinated nerve fibers. When action potentials reach the terminal of a motor axon, the resulting depolarization of the terminal causes membrane channels to open, allowing external calcium ions to enter the axon. The vesicles are all approximately the same size and all release about the same amount, or quantum, of neurotransmitter. The opening of the channels depends only on the presence of neurotransmitter and not on membrane voltage. Sodium and potassium permeability changes occur simultaneously, and both ions share the same membrane channels, but the change in electrochemical gradient for sodium into the cell is much greater than that for potassium out of the cell. The result is a net inward positive current that depolarizes the postsynaptic membrane. Endplate potentials are simple local depolarizations that are transmitted outward (leak) from underneath the motor endplate. They diffuse from their initial location with decrement, that is, their amplitude decays as they travel through the myoplasm. The motor endplate does not contain voltage-gated sodium channels and cannot produce self- propagating action potentials. However, regions of the sarcolemma away from the motor endplates do contain voltage-gated sodium channels. If these channels can be brought to threshold, the muscle fiber can form self-propagating action potentials in a manner analogous to that in unmyelinated neurons. However, because endplate potentials move down the muscle fiber with decrement, an initial small endplate potential may be of insufficient amplitude by the time it reaches a sodium channel to bring that channel to its threshold for firing an action potential (see Fig. Although this endplate potential will also spread out across the muscle membrane with decrement, enough depolarization will reach the region of voltage-gated sodium channels in the muscle membrane to cause them to open and fire an action potential. Once formed, the muscle action potential will then be self- propagating along the muscle cell membrane as with a nonmyelinated nerve fiber. Under normal circumstances, the endplate potential is much more than sufficient to produce a muscle action potential; this reserve, or safety factor, can help preserve function under abnormal conditions. Presynaptic blockade can occur if calcium does not enter the presynaptic terminal. Postsynaptic blockade can result from drugs that can bind to nicotinic receptors in the muscle membrane. Abnormal postures and considerable pain, as well as physical impairment, often result. Usually, the abnormal contraction is limited to a small and specific region of muscles, hence the term focal (by itself). Such problems are neurologic, not psychiatric, in origin, and sufferers can have severe impairment of daily social and occupational activities. Although the specific cause is located somewhere in the central nervous system, the exact nature of dystonia is unknown. Centrally acting drugs are of limited effectiveness, and surgical denervation, which carries a significant risk of permanent and irreversible paralysis, may provide only temporary relief. Botulinum toxin, which produces chemical denervation of motor neurons resulting in flaccid muscle paralysis, has shown potential benefit in the treatment of dystonias. Botulinum toxin is produced from the bacterium Clostridium botulinum and is one of the most potent natural toxins known; a lethal dose for a human adult is about 2 to 3 μg. Type A toxin, the complex form most often used therapeutically, is sold under the trade names Botox and Oculinum. The toxin first binds to the cell membrane of presynaptic nerve terminals in skeletal muscles. The initial binding does not appear to produce flaccid paralysis until the toxin is actively transported into the cell, a process requiring more than an hour. Once inside the cell, the toxin disrupts calcium- mediated acetylcholine release by binding to docking proteins that link synaptic vesicles containing neurotransmitter to the nerve terminal membrane. This prevents action potentials from being able to release neurotransmitter into the neuromuscular junction. The transmission block at the neuromuscular junction of the affected neuron is irreversible. The nerve terminals begin to degenerate, and the denervated muscle fibers atrophy. Eventually, new nerve terminals sprout from the axons of affected nerves and make new synaptic contact with the chemically denervated muscle fibers. During the period of denervation, which may be several months, the patient usually experiences considerable relief of symptoms. The relief is temporary, however, and the treatment must be repeated when reinnervation has occurred. Clinically, highly diluted toxin is injected into the individual muscles involved in the dystonia. Recently, Botox has been used to treat retractable esophageal dysmotility disorders that are refractory to other forms of treatment. In dystonias involving muscles in the extremities, injections of toxin are done in conjunction with electrical measurements of muscle activity (electromyography) to pinpoint the muscles involved. Depending on the specific disorder, relief may be dramatic and may last for several months or more. The abnormal contractions and associated pain are greatly reduced, speech can become clear again, eyes reopen and cease uncontrolled movements, and, often, normal activities can be resumed. However, this property has been exploited for the cosmetic use of Botox for releasing muscle tension in the face and forehead, which then reduces the formation of wrinkles in the skin. Studies have shown that the toxin’s activity is confined to the injected muscles, with no toxic effects noted elsewhere. The outer surface of a skeletal muscle fiber is surrounded by an electrically excitable cell membrane supported by an external meshwork of fine fibrous material. The sarcolemma generates and conducts action potentials much like those of nerve cells. This organelle plays a key role in controlling muscle contraction because the free calcium ion concentration within the muscle fiber is critical in controlling the processes of contraction and relaxation (see details below). The longitudinal element forms a system of hollow sheets and tubes that are closely associated with the myofibrils. The ends of the longitudinal elements terminate in a system of terminal cisternae (or lateral sacs). These contain a protein, calsequestrin, that weakly binds calcium, and most of the stored calcium is located in this region. Closely associated with both the terminal cisternae and the sarcolemma are the transverse tubules (T tubules), which are inward extensions of the cell membrane whose interior is continuous with the extracellular space.

All major ligament injuries as if the foot moved on a fxed tibia order kamagra super with american express erectile dysfunction uk, but must be torn cheap kamagra super 160mg overnight delivery impotence 21 year old, resulting in an unstable frac- e purchase kamagra super with a mastercard doctor for erectile dysfunction philippines. Clinical Features fractures with crushing of the muscles The momentum of the body may impose • The patient may have stumbled over an and tendons with skin loss around the one of the variety of forces upon the ankle unexpected obstacle or stair or may have ankle. The ankle is twisted external rotation, abduction and adduc- severely under the leg. Two things should be noted in this • Pain, swelling and deformity appear rap- • Wound infection connection viz. The foot is inherently more stable in • The site of tenderness is important, if • Joint stifness and pain eversion than inversion. On exami- • Extra-articular fractures are managed nation there is tenderness at the site of Tis occurs due to fall from a height. A gap is felt in the course of the calcaneum is driven against the talus and is displaced intra-articular fractures are tendon 5 cm above its insertion. Simmonds Test Calcaneal fractures can be divided into Tis is a useful test to diagnose the condi- two groups (Fig. With the patient lying in prone posi- • Extra-articular fractures (75%)-Involve • Broadening of the heel. Tey are easy to manage and the ruptured tendon side the foot remains have a good prognosis. Tis is a pathological tear of tendoachilles Treatment about 5 cm above the insertion of the tendon. Conservative-Tis is preferred especially Clinical Features Such tear occurs through an area of avascular in sedentary or elderly patients and is done The foot is swollen, painful and bruised. The degeneration during vigorous physical activ- with (i) plaster immobilization for 8 weeks heel may look broad and squat and the nor- ity. X-Ray: Extra-articular fractures are quite • Tis injury usually afects middle-aged The tendon is repaired with nonabsorbable obvious. X-ray of spine and pelvis are important as in nizing pain at the back of the ankle while If the rupture is neglected for 4 weeks, any severe injury. A septic focus ofen acts as a source of by edema with infammatory exudate and infection, e. Osteomyelitis can be defned as the infection tis media, acute umbilical sepsis, acute of bone with all its components viz. Precipitating or exciting factors: or has been subjected to early and efcient types a. Chronic osteomyelitis which may be: organism responsible is Staphylococcus arterial thrombosis resulting in wide- i. Chronic pyogenic responsible include the Streptococcus The infection process rarely crosses the b. Pus goes towards the surface to lie under Pathology the periosteum and forms a subperiosteal Organisms reach the bone through the blood- abscess (Fig. Acute pyogenic stream from a septic focus elsewhere in the If the metaphysis is intracapsular, e. Predisposing factors: physeal arteries, there is stagnation and and eventually separates from the living bone a. Age-Children aged between 2-10 slowing of circulation so that the organ- as a sequestrum (Fig. Afer settling, the organisms induce an beneath the stripped up periosteum forming b. The development of sequestrum and formation (periosteal reaction) at the Surgical Treatment involucrum are all well-established in chronic metaphysis. Bone scan-A bone scan using techne- perature does not subside and no clinical only beginning of sequestrum formation. Clinical Features tive before the changes appear on the Under general anesthesia, the afected • Children, especially boys are the usual X-ray. Treatment made in the bone in the region of the meta- • Onset is rapid and pain is the presenting • A patient of acute osteomyelitis is gener- physis. Local Examination • An intravenous line is secured and nonster- Rest, antibiotics and hydration are contin- • Swelling and local rise of temperature. Antibiotics are contin- • Skin overlying the area is glossy, reddish are advised for relief of pain. Septicemia and pyemia which may give swelling of the adjacent joint, because of substituted if they are indicated by the rise to metastatic abscesses. Culture must be done along with sensi- Local Treatment ment will lead to this complication. No movement of the afected limb is myelitis is diferentiated from this condi- earliest sign is periosteal new bone encouraged. The point of greatest tenderness is over recurrently but in presence of sequestrum, it Complications the bone rather than the joint. Scurvy: Tere is subperiosteal hematoma • Bone is palpably thickened and there are iii. Lengthening due to increased vascu- formation which mimics acute osteomy- nearly always a number of overlying scars larity of the growth plate due to the elitis on X-ray but the absence of pain, or sinuses. Treatment of chronic osteomyelitis is prima- • Sequestrum-Tis is seen as a dense rily surgical. The aim of surgery is the removal chronic osteomyelitis loose fragment with irregular but of the infected granulation tissue and sinuses Chronic osteomyelitis generally denotes sharply demarcated edges lying within as well as the dead bone or sequestrum. Radioisotope scanning shows increased sequestrectomy with saucerization (shal- tion, etc. Chronic osteomyelitis secondary to acute sequestrum, thus allowing accurate plan- which allows free drainage of the infected osteomyelitis ing of operative treatment. The beads are then gradually Two factors are responsible for the chronicity pulled daily afer 4 to 6 weeks of stay. The presence of dead infected bone or beads is subsequently flled by a fap of sequestrum, which cannot be absorbed. The intraosseous abscess cavity which can (Syn-Chronic Bone Abscess) not be obliterated because of its rigid bony Tis is a special form a chronic osteomyelitis, walls. The bone Tere is a localized abscess within a bone, is generally thickened and is generally denser near the metaphyses (Fig. The residual cavity is flled with cancel- entiated from the bone tumors which may lous bone chips. Sometimes making a • X-ray shows a circular or oval cavity sur- ensuing irritation. The rest of and tibia are the most commonly afected See also the long case osteomyelitis in the bone is normal.

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A steeple sign may also be observed in patients without • Nebulized epinephrine (adrenaline): {{ It is used for children with moderate-to-severe respira- croup discount kamagra super erectile dysfunction 2, such as epiglottitis buy kamagra super american express impotence natural, thermal injury cheap kamagra super 160 mg otc erectile dysfunction treatment photos, angioedema, or bacterial tracheitis. Efectiveness of standard epinephrine 1:1,000 (which is available in India) is the same as Laryngoscopy and/or bronchoscopy are indicated only in racemic epinephrine, when given in dose of 0. Patients can be discharged home if they demonstrate good color, adequate air entry, baseline consciousness, and no stridor at rest and have received a dose of A corticosteroids • Corticosteroids: they act through anti-infammatory action, whereby decreasing mucosal edema and also decreasing the need for nebulized epinephrine. In moderate to severe disease, it improves croup scores within 12–24 hours and decrease hospitalization rates. Using inhaled corticosteroids (budesonide) along with systemic steroid does not provide additional beneft – Usage of steroids has no signifcant adverse efects; however, it should be carefully evaluated for children with diabetes/immunocompromised state, recently diagnosed with varicella or tuberculosis. Poor ability to • Antibiotics are not needed, as etiology is viral infection maintain adequate oral intake plus increased insensible fuid • Heliox:Currently, the evidence is not sufcient to losses can lead to dehydration. The majority of patients are managed successfully as Complications in croup are rare. A secondary bacterial infection may rarely result in Spasmodic croup (laryngismus stridulus) may be a non- pneumonia or bacterial tracheitis, a life-threatening infection. Utility of bronchoscopy for recurrent night with the sudden onset of “croupy” cough and stridor. Comparison between single-dose oral prednisolone and oral patient becoming sensitized to viral antigens. Budesonide offers no advantage when added to oral dexamethasone symptoms when treated for refux. Correlating the clinical course of recurrent croup with endoscopic fndings: a retrospective observational study. Ann Otol ){It is a viral (parainfuenza) infection with subglottic airway Rhinol Laryngol. Steroid treatment of laryngotracheitis: a diferentiate it from supraglottic pathology meta-analysis of the evidence from randomized trials. Practical Pediatric Imaging: Diagnostic Radiology of Infants and Children, 3rd edition. Philadelphia, Pa: Lippincott-Raven; ){Assessment of severity is clinical, which decides treatment 1998. Controlled delivery of high vs low humidity vs mist therapy for croup in emergency 1. Red Book: 2003 Report of the Committee on Infectious Diseases, 26th randomised equivalence trial. Encephalopathy is a difuse disease afecting the brain that Encephalitis alters its structure or function and may be caused due to diverse Encephalitis means infammation of the brain. It is strictly a etiology like infective, metabolic, toxic, ischemic, nutritional pathological diagnosis; but surrogate clinical/imaging markers causes or trauma. Other early clinical fndings may include an increase implicated in the etiology; and the proportionate contribution in irritability, somnolence, or abnormal behavior greater than of each varies according to the geographical area. Even after a detailed diagnostic workup, one may not be according to the etiology. Encephalopathy generally results able to arrive at a defnitive diagnosis in many cases. Despite a Encephalopathy describes a clinical syndrome of altered wide array of pathophysiologic mechanisms, the clinical mental status, manifesting as reduced consciousness or altered manifestations tend to be very similar because of the common behavior, without any infammation of the brain. At the outset, (Lyme disease), Leptospira, Brucella, and Salmonella it is important to diferentiate infective from non­infective typhi causes, because infection mandates prompt antimicrobial {{ Rickettsial infections, fungal infections due to crypto­ therapy. There are no distinguishing clinical or radiological coccosis, histoplasmosis, coccidioidomycosis, and features to diferentiate the various causes of viral encephalitis. Cerebral ischemia is the single­most important of paramount importance as the children with impaired determinant that decides the outcome of such patients. These Once the airway and breathing have been addressed, children have loss of tone of the oropharyngeal muscles circulation must be evaluated. This involves assessment of causing the tongue to fall back and obstruct the airway, and the cardiac output. Symptoms of shock include tachycardia, pooling of secretions (leading to aspiration). Measures should cool extremities, delayed capillary refll time, mottled or pale be taken to secure the airway. Hypotension is a late fnding in airway obstruction, repositioning of the head with the chin lift shock. Vascular access is necessary for volume resuscitation maneuver may alleviate the obstruction. While establishing an is suspected, a jaw thrust maneuver is preferable and the neck intravenous access, samples should be drawn for various immobilized while securing the airway. If there is evidence of circulatory failure, fuid inserted if required and secretions cleared using a large­bore­ bolus (20 mL/kg of normal saline; maximum 60 mL/kg) suction cannula. If there is evidence of septic shock, Once the airway patency has been established, the larger volumes (60–80 mL/kg) may be needed to correct the adequacy of breathing should be evaluated. Once an intervention is performed, the clinician must the lung felds should assess for air entry, symmetry of breath reassess the patient. Pulse oximetry can be used to evaluate circulation through intravenous isotonic fuid administration oxygenation. Oxygen should be administered to all seriously­ and inotropes, if necessary, is essential to deliver oxygen ill children via non­rebreathing face mask. Adequacy of and metabolic substrates to the brain and remove toxic ventilation should be assessed by examination and arterial metabolites. Extreme hyperventilation has been associated and inappropriately treat with antiepileptic drugs. Hence, its absence must be identifed and treated appropriately, as unrecognized not be taken as a reassuring sign. Eforts should be It should not be administered round the clock and is unlikely taken to provide pain relief and sedation during painful to be efective after 48–72 hours. A neurosurgical benefts of relieving agitation outweigh the need for close consultation should be asked for. The use ){Identify and treat aggravating factors-seizures, noncon- of therapeutic hypothermia (32–34°C) may be appropriate vulsive status epilepticus, fever, pain, anxiety for children with out­of­hospital arrest and persistent coma ){Continuous monitoring of heart rate, respiratory rate, blood or those with ventricular fbrillation or pulseless ventricular pressure, temperature, oxygen saturations, electrocardiogram, tachycardia. T ereafter, the sugar levels should be monitored and the glucose infusion rates History (Table 3) modifed accordingly. Hyperglycemia resulting from stress is The patient’s history may hold the most important and a more common fnding in these conditions. Central nervous system benzodiazepine followed by phenytoin loading 20 mg/kg or infections, on the other hand, would present with complaints fosphenytoin) should be administered. The standard protocol evolving over a few days associated with a history of fever or 148 for the management of status epilepticus may be followed in recent illness. The presence of fever suggests an infective process (sepsis, The associated symptoms may indicate the focus of pneumonia, meningitis, encephalitis, or brain abscess); but infection. Symptoms such as headache, nausea and vomiting, may also indicate heat stroke or abnormality of hypothalamic irritability, seizures, focal defcits, rash, and joint pain temperature regulatory mechanisms. Other concurrent systemic result of fever, hypovolemic or septic shock, heart failure, or illnesses, e.

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Adding 63 solution to each white cup and note which cup shows alum also results in some decrease in bacterial content of supernatant water after the flocculum has settled • Removal of hardness-Temporary hardness is down cheap kamagra super 160 mg visa erectile dysfunction treatment in kl. These filters are of various types- On a large scale both types of hardness are Pasteur-Chamberland type (candle made of diato- removed by the base exchange or permitted maceous infusorial earth called kieselgurh) or Katadyn method purchase kamagra super 160mg online impotence in the bible. Permutit or sodium permutit is a complex type (in which the filter is coated with a silver catalyst compound with the formula Na2Al2Si2O H2O buy kamagra super 160mg low price erectile dysfunction specialists. Once the activity after constant use, hence it should be scrubbed with a of sodium permutit is exhausted, it can be regene- hard brush every 3 days and boiled at least once a week. Sometimes additional techniques may be needed for • Removal of fluorides, iron and arsenic Practical water purification beside those described above. These technology for defluoridation plants, iron removal are briefly described below: plants and arsenic removal plants suitable for Indian • Active charcoal-This may be used to remove bad conditions is now available. The bacterial content is also reduced In the preceding section, various procedures partially. Efficacy may vary depending upon design, operation, water 64 quality and temperature. Prechlorination treatments like slow and or biological filtration, flocculation with rapid filtration and lime flocculation are highly effective and may reduce viruses by 90%. However, all these alone are not adequate and disinfection is the most effective treatment for removal of viruses. Protection of environment and safeguarding of health on all 4 sides, there is a gutter just above the water level through integrated management of water resources for spitting. Institutional reforms, including changes in procedures, Facilities: These include drinking water, lavatories and attitudes and behavior, to promote an integrated bathrooms with shower. The operative norms for rural water supply are as The water of the swimming pool can be purified by follows: a continuous method or by a fill and empty system. The • Water to be free from biological and chemical pool is emptied once in 14 days to scrub the walls and contamination. Water Problem in India References There is widespread scarcity of water in India for agriculture as well as domestic use. Appropriate Technology for Water of water, scientific location of water resources and Supply and Sanitation. They may reach man an essential part of housing not only because it provides through water and vegetables. In addition, soil also forms part of occupational environment in case of farmers, laborers and potters, Biological Agents etc. Hence, it is appropriate to consider first of all the implications of soil as part of man’s physical All sort of life subsists on or in the soil and it may be regarded as a living community of fungi, bacteria, proto- environment. Soil bacteria Types of Soil dispose of all the organic waste matter dumped on the soil, if the required warmth, oxygen and moisture are The superficial layer of soil is called supersoil and is made available. They break up complex nitrogenous matter, of decaying animal and vegetable matter (humus) such as proteins, into ammonia, H2S and simple mixed with sand, dust and stone particles. The soil nitrogenous compounds and finally convert them by below the surface is called subsoil which may be: oxidation into end products such as nitrites, nitrates, • Rocky or stony, made up of chalk, limestone, sand- carbonates, chlorides and sulphates. Bacterial decomposition of organic matter • Filled or made soil: Soil made up by filling low lying is minimum in rocky soil and maximum in loamy soil. It is not suitable for It may occur slowly in clayey and moist soils, which making a house for 10 to 15 years as it sinks and contain too much moisture. Most of the bacteria in earth are in surface soil, their number and activity decreasing with depth. Physical Agents Others survive if the soil is favorable and contains air, moisture and organic matter. The following pathogenic Rocky and sandy soil make the climate hot while clayey organisms may be found in soil: soils make it damp and cold. Any wound polluted with such in Kerala, or may be polluted with radioactive fall-outs. These include igno- – Ova of helminths: Roundworm ova are very rance, poverty, traditions, fear of theft and dacoity, hardy and can survive long in soil, upto years. Hookworm larvae can survive for two months A model village house sould have the following in damp soil. They may The huts or houses should be built in parallel lines, with infect the soil, particularly in mines. Finally, it may be mentioned that polluted soil results in four major health problems. Green vegetation around the house in the form of vegetable, Housing flowers and trees makes the environment pleasant and Housing, as an environment, means the building or healthier. It should have at least two rooms with a separate kitchen They should be so constructed and laid out as to 2-4 and verandah. The built up area should not exceed one promote physical, mental and social well-being. There should be two windows, opposite For physical well-being the house must provide each other, at least 1 m × 0. It must be constructed on firm in size with impervious floor and white washed walls. The kitchen should have a smokeless chullah For mental well-being the house should afford and a chimney for smoke outlet. For social well-being, the size and construction of the It should be at least 8 to 10 meters away from the living house and the amenities provided should be house and should be open on all sides. A provision of compatible with human dignity and social respectability; 3 square meter per head of cattle is adequate. Urban Housing Rural Housing Old towns and cities have developed without proper Village and small towns often come up and grow planning. Yet, people live in dark, ill ventilated, damp and Public places such as playgrounds, parks, gardens, schools, libraries, markets, swimming pools and • Water supply of the house should be adequate along entertainment theaters, etc. The problem is made worse by ever growing • Sanitary latrine of approved type should be provided. One-fourth of world • Ample space and other arrangement should be population was living in cities and towns in 1959. By provided for domestic occupations such as dairying, 2025, this proportion is expected to reach 60 percent. In addi- the nuisance of dust, smoke, foul smell and exces- tion, scabies and louse infestation are more common in sive noise. Poor living conditions also have indirect • The set back should be such as to permit enough effects on mental and social health, resulting in more light and ventilation. Built up area should not be school drop outs, delinquency, drug abuse, crimes and more than one third in thinly populated and more other antisocial acts.

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This response may contribute to the state of shock that often accompanies crushing injuries and/or joint displacement generic kamagra super 160mg line impotence restriction rings. Dilation of cutaneous vessels promotes heat loss (as long as the environmental temperature is below the body temperature) generic kamagra super 160 mg online impotence sentence examples. Temperature regulation responses are controlled primarily by the hypothalamus discount kamagra super online american express erectile dysfunction treatment viagra, which can operate through the cardiovascular centers to discretely control the sympathetic activity to regulate vasoconstric­ tion of cutaneous vessels and thus skin blood flow. Measurable changes in cutaneous blood flow result from changes in hypo­ thalamic temperature of tenths of a degree Celsius. Cutaneous vessels are infuenced by reflexes involved in both arterial pressure regulation and temperature regulation. When the appropriate cutaneous vascular responses for temperature regulation and pressure regulation are contradictory, as they are, for example, during strenuous exercise, then the temperature regulating infuences on cutaneous blood vessels usually prevail. Summary Most of the infuences on the medullary cardiovascular centers that have been discussed in the preceding sections are summarized in Figure 9-4. This fgure is intended frst to reemphasize that the arterial baroreceptors normally and con­ tinually supply the major input to the medullary centers. The arterial baroreceptor input is shown as inhibitory because an increase in arterial baroreceptor fring rate results in a decrease in sympathetic output. Summary of the factors that influence the set point of the arterial baroreceptor refex. Note that certain responses that have been discussed are not included in Figure 9-4. The complex combina­ tion of stimuli involved in the dive reflex causes simultaneous sympathetic and parasympathetic activation and cannot be simply classifed as either pressure rais­ ing or pressure lowering. Also, temperature stimuli that discretely afect cutaneous vessels, but not general cardiovascular sympathetic and parasympathetic activity, have not been included in Figure 9-4. The nonarterial baroreceptor infuences shown in Figure 9-4 may be viewed as disturbances in the cardiovascular system that act on the medullary cardiovas­ cular centers as opposed to disturbances that act on the heart and vessels. These disturbances cause sympathetic activity and arterial pressure to change in the same direction. Recall from the discussion of the arterial baroreceptor refex that cardio­ vascular disturbances that act on the heart or vessels (such as blood loss or heart failure) produce recirocal changes in arterial pressure and sympathetic activity. These facts are often useful in the clinical diagnoses of blood pressure abnor­ malities. These same-direction changes in arterial pressure and sym­ pathetic activity suggest that the problem lies not in the periphery but rather with an abnormal pressure-raising input to the medullary cardiovascular centers. The physician should immediately think of those set point-raising infuences listed in the top half of Figure 9-4 that would simultaneously raise sympathetic activity and arterial pressure. Often, such a patient does not have chronic hypertension but rather is just experiencing a temporary blood pressure elevation due to the anxiety of undergoing a physical examination. A more rigorous analysis of the operation of the arterial barorefex is presented in Appendix E. The most long-standing and generally accepted theory of long-term pressure regulation is that it crucially involves the kidneys, their sodium handling, and ultimately the regulation of blood volume. This theory is some­ times referred to as the "fuid balance" model of long-term arterial blood pressure control. First is the fact that the baroreceptor refex, however well it counteracts temporary disturbances in arterial pressure, cannot effectively regulate arterial pressure in the long term for the simple reason that the baroreceptor fring rate adapts to prolonged changes in arterial pressure. Recall that the whole purpose of arterial pressure is to cause blood tofw through tsues. Thus, it makes little long-term sense to increase arterial pressure by throttling blood fow with refex arteriolar constriction. Because blood volume is one of the components of the total body fluid, blood volume alterations accompany changes in total body fluid volume. The mechanisms are such that an increae in arterialpressure causes an increase in uri­ nary output rate and thus a decreae in blood volume. But, as outlined in the pre­ ceding sequence, decreased blood volume tends to lower arterial pressure. Tus, the complete sequence of events that are initiated by an increase in arterial pres­ sure can be listed as follows: i Arterial pressure (disturbance) J i Urinary output rate J J Fluid volume J J Bloodvolume J J Cardiac output J J Arterial pressure (compensation) Note the negative feedback nature of this sequence of events: increased arterial pressure leads to fluid volume depletion, which tends to lower arterial pressure. Conversely, an initial disturbance of decreased arterial pressure would lead to fuid volume expansion, which would tend to increase arterial pressure. Because of negative feedback, these events constitute afuid volume mechanism for regulat­ ing arterial pressure. As indicated in Figure 9-5, both the arterial baroreceptor refex and this fluid volume mechanism are negative feedback loops that regulate arterial pres­ sure. Although the arterial baroreceptor reflex is very quick to counteract distur­ bances in arterial pressure, hours or even days may be required before a change in urinary output rate produces a signifcant accumulation or loss of total body fluid volume. Whatever this fluid volume mechanism lacks in speed, however, it more than makes up for that in persistence. As long as there is any inequal­ ity between the fluid intake rate and the urinary output rate, fluid volume is changing and this fuid volume mechanism has not completed its adjustment of arterial pressure. The fuid volume mechanism is in equilibrium only when the urinary output rate exactly equals the fuid intake rate. The processes that regulate voluntary fluid intake (thirst) are not well understood but seem to involve many of the same factors that infuence urinary output (eg, blood volume and osmolality). Preventive and Social Medicine is comparatively a improvement in economic condition or education and newcomer among the academic disciplines of medicine. Previously it was taught to medical students as hygiene Among the developing countries, India gave a lead and public health. This name was later changed to for bringing about the total well being of rural people preventive and social medicine when it was realized that by instituting the remarkable Community Development the subject encompassed much more than merely the Program (1951). For intensive all-round development, principles of hygiene and sanitation and public health the country was divided into Community Development engineering. The name preventive and social medicine Blocks in which ill-health was to be fought through the emphasizes the role of: (a) disease prevention in general agency of primary health centers as recommended by through immunization, adequate nutrition, etc. It may be mentioned that the addition to the routine hygiene measures, and (b) social concept of public health was fairly well developed in factors in health and disease. Adequate proof of community health The name preventive and social medicine has gained measures adopted during Harappa Civilization as far as wide acceptance in the past twenty-five years or so 5000 years ago has been found in the old excavations because of its broader and more comprehensive at Mohenjo-Daro and at Lothal near Ahmedabad in the outlook on medicine, integrating both prevention and form of soakpits, cesspools and underground drainage. Today, it implies a system of total health care delivery to individuals, families and communities at the Public Health, Preventive clinic, in the hospital and in the community itself. Medicine, Social Medicine and Community Medicine Historical Background Traditionally, a young man planning to enter the medical During last 150 years, there have been two important college has in mind the picture of a patient in agony, “revolutions”. The industrial revolution in 1830 was in relieving whose suffering by medicines he considers associated with the discovery of steam power and led himself to be amply rewarded. He always thinks of to rapid industrializations, resulting in concentration of alleviating the suffering of a patient but rarely about the wealth in the cities and, consequently, migration from prevention of such suffering at the level of the individual rural to urban areas. No doubt he has hand the villages were neglected and, on the other, the to play a very important role in meeting the curative towns and cities witnessed rapid haphazard expansion, needs of society but that is not all. But now brought in their wake and more complex health the developing society, in India and elsewhere, expects problems in rural as well as urban areas which ultimately much more from the doctor, and the people are led to development of the concept of public health.