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By Z. Basir. Coppin State College.

Insufficient Fresh whole fruit – – Exposure to fluoride in some countries has altered the sugars caries relationship and widespread exposure to 189 fluoride may increase the level of safe intake order avalide 162.5 mg on line prehypertension blood pressure treatment. Sheiham Table 8 Summary of the strengths and weaknesses of the argues that where fluoride in drinking-water is at 0 generic avalide 162.5 mg otc arrhythmia questions. Policies on sugars intake in different countries Table 9 Summary of the strengths and weaknesses of the A number of countries have adopted policies/recommen- evidence linking diet to periodontal disease dations for free sugars (also referred to as ‘added’ ‘purified’ Increased No Decreased ‘non-milk extrinsic’ or ‘refined’) intake based on these risk relationship risk data—these are summarised in Table 11 discount avalide 162.5mg online arteria fibrillation. Exposure to fluoride alone may not eliminate Policy implications—potential strategies caries but trusted avalide 162.5mg blood pressure 200120, along with reduction in free sugars intake, it has a significant effect on caries prevention. Research into Strategies to prevent dental caries: modification of effective means of delivering optimum exposure to free sugars consumption fluoride should continue. It is important to note that A summary of the research indicating theoretical safe/ many countries that are currently undergoing nutrition acceptable levels of intake for free sugars is given in transition do not have adequate exposure to fluoride. It is important at the population level to have a maximum level of intake for free sugars because a wealth Promotion of good oral hygiene of evidence shows that when free sugars intake by a There is no strong evidence of a clear relationship 192 population is low, dental caries levels are low. The population goal based on amount of free sugars intake Health Education Authority in England concluded that also enables the dental health risks of populations to be ‘although caries cannot develop without the presence of assessed and health promotion goals monitored. Normal brushing 187,188 dental caries and levels of sugar is S-shaped inevitably leaves some plaque in fissures and in other (Table 10). At low levels of sugar intake (#10 kg/ stagnation sites where caries occurs and plaque rapidly person/yr (27. While annual sugar consumption is above 15 kg/person/yr toothbrushing is important for maintaining gingival health, (40 g/d) dental caries increases and intensifies with numerous studies have failed to establish a clear increasing sugar availability. Annual caries Data from Japan increment was positively related to sugars when annual sugar intakes ranged from 0. Caries levels increased Data from Japan 1945–1987 as sugars intake increased until a peak was reached at 29kg/yr in 1973. Tooth- 1986 Netherlands, Ministry of Health 0–10% brushing with fluoride toothpastes has been shown to be 1987 Australia, Department of Health #12% 194 an effective caries preventive measure’. Population goals enable the oral health important method for delivering fluoride to the tooth risks of populations to be assessed and health promotion surface. In an extensive review of epidemiological data dental caries is low in countries where the consumption of concerning the role of oral hygiene in caries prevention, free sugars is below 15–20 kg/person/yr. This is equival- Sutcliff concluded ‘although toothcleaning with un- ent to a daily intake of 40–55 g and the values equate to medicated agents may be expected to reduce caries 6–10% of energy intake. It is of particular importance that experience, the lack of consistent epidemiological countries which currently have low consumption of free corroboration of the relationship has led to questioning sugars (,15–20 kg/person/yr) do not increase consump- of the value of oral hygiene practices against caries. Governments should establish the means of amount of free sugars, targets for frequency of free sugars monitoring the severity and prevalence of oral diseases consumption are also important. There should be promotion of adequate fluoride exposure Governments should support research into elucidating via appropriate vehicles, for example affordable tooth- optimum fluoride intake by different age groups and paste, water, salt and milk. It is the responsibility of effective means of delivering optimum fluoride and national health authorities to ensure implementation of should also support research into nutrition and dental feasible fluoride programmes for their country. Governments should ensure that teachers, pupils and In order to minimise the occurrence of dental erosion, health professionals receive adequate education on diet, the amount and frequency of intake of soft drinks and nutrition and dental health issues. Elimination of undernutrition also provide guidelines for the use of and content of prevents enamel hypoplasia and the other potential effects educational materials to ensure they are sound and non- of undernutrition on oral health (e. Governments should set more stringent codes of practice on advertising (including advertising and infor- mation on the Internet) of sugars-rich items. Recommendations to international organisations Recommendations to private sector and industry for the prevention of dental diseases Food manufacturers should continue to produce low- The potential financial consequence of failing to prevent sugars/sugars-free alternatives to products rich in free dental diseases need to be highlighted, especially to sugars, including drinks. Manufacturers should also look governments of countries that currently have low levels of at means to reduce the erosive potential of soft drinks. The To enable individuals to make informed choices detrimental impact of quality of life throughout the life regarding the oral health/dental problems related to high course and the longer-term nutritional consequences of and frequent free sugars intake, there is a need for clear and dental disease and tooth loss also need to be highlighted. Oral health education should be promoted sugars and soft drink intake and should provide guidance alongside other forms of health education and dietary and to nations on standardised methods for data collection on nutrition advice for oral health should be integrated with appropriate study populations where necessary. This is essential if advice for fluoride toothpaste is available/affordable, individuals dental health is to be consistent with dietary advice for should be encouraged to brush their teeth with a fluoride general health. Oral health status of children and research and/or information are as follows: adults in the Republic of Niger, Africa International Dental Journal 1999; 49: 159–64. More information is needed from longitudinal studies 8 Kelly M, Steele J, Nuttall N, Bradlock G, Morris J, Nunn J, or repeated cross-sectional studies (e. Intake of non- juices and other acid-containing foods needs to be starch polysaccharide (dietary fibre) in edentulous and monitored. Nutrient intake in partially dentate patients: the effect of prosthetic rehabilita- An earlier version of this paper was prepared as a tion. Nutrition and dental caries: ten findings to be Consultation on diet, nutrition and the prevention of remembered. Pathogenesis and modifying Sweden, for their comments on an earlier draft of the factors of dental erosion. Oral health status of children Final report on the effect of sucrose, fructose and xylitol Diet, nutrition and prevention of dental diseases 223 diets on the caries incidence in man. Compendium of National Diet and Nutrition Survey: young people aged Continuing Education in Dentistry 2002; 23: 431–6. Incidence and distribution of Strep mutans in distribution and severity of tooth wear and the relationship plaque from confectionery workers. Journal of Dental between erosion and dietary constituents in a group of Research 1979; 58(Special issue): 2251. Journal of use of fluorides on caries increment in children during one Dental Research 1963; 42: 1387–99. Comparison of increment assessed over two years in 405 English dietary habits and dental health of subjects with hereditary adolescent schoolchildren. Effect of the length Community Dentistry and Oral Epidemiology 1981; 9: and number of intervals between meals on caries in rats. Longitudinal study of caries, cariogenic bacteria and diet and oral hygiene for the occurrence of caries in 3-year-olds. Dental health, Caries prevalence, Streptococcus mutans and sugar intake dental care and dietary habits in children in different among 4-year-old urban children in Iceland. Infant tion and caries experience in 12- and 13-year-old feeding and dental caries, a longitudinal study of Swedish Icelandic children. Epidemiological study of dental malocclusion, fluoride usage, toothbrushing and dietary caries experience and between-meal patterns. Community Dentistry and oral health behaviour of 12-year-old urban schoolchildren Oral Epidemiology 1992; 20: 133–7. Multiple regression cariogenicity of different dietary carbohydrates tested on analysis of dental status and related food behaviour of rats in relative gnotobiosis with a streptococcus producing French Canadian adolescents. The effects of phosphates on guidelines on sugar intake and dental caries in 3-year-olds experimental dental caries: a literature review. International Journal of Paediatric Dentistry 119 Frostell G, Birkhed D, Edwardsson S, Goldberg P, Petersson 1996; 6:81–6. Identification of low caries risk dietary com- sugar from sucrose in combination with duraphat treatment ponents. Dental caries in children one to six salivary bacterial levels in 12-year-old English school- years of ages as related to socio-economic level, food habits children. The effects of starch and sugar diets on dental glucose syrups in experiments in vitro and in the diets of caries. Journal of the American Dental other sugar analogues on acid production from sugars by Association 1980; 100: 677–81.

If it is caused by a H5N1 virus discount 162.5 mg avalide otc blood pressure medication hydralazine, the neura- minidase inhibitors oseltamivir and zanamivir may be critical in the planning for a pandemic (Moscona 2005) discount avalide 162.5 mg on-line blood pressure medication isn't working. Even in countries which have stockpiled oseltamivir avalide 162.5 mg with visa blood pressure pump, distribution of a drug that is in short supply will pose considerable ethical problems for treatment avalide 162.5 mg generic hypertensive urgency treatment. Global Management The management of an influenza outbreak is well-defined for epidemics, and less well-defined for pandemics. Vaccine production is a well-established procedure: throughout the year, influenza surveillance centres in 82 countries around the world watch circulating strains of influenza and observe the trends. Pre- dicting the evolutionary changes of the viral haemaglutinin is not easy and not al- ways successful. In years when the anticipated strain does not match the real world strain, protection from influenza vaccine may be as low as 30 %. Managing uned- ited situations requires some appreciation of the magnitude of the problems that lie ahead. The impact on human health may be highly variable and is expressed in the number of • infected individuals • clinically ill individuals • hospitalised patients • deaths. It is generally assumed that during the first year of the next pandemic 2 billion peo- ple will become infected with the new virus and that half of them will have symp- toms. Less accurate are the estimates of the number of people that will require hos- pitalisation and the death toll. During the 1957 and 1968 pandemics, the excess mortality has been estimated at around one million deaths each. Excess mortality during the last influenza pandemics varied from 26 to 2,777 per 100,000 population (Table 2). A devastating pandemic might therefore, in the course of only a few months, cause three times as many deaths as would normally occur in an entire year. In a world of extensive mass media coverage of catastrophic events, the resulting atmosphere would probably come close to war-time scenarios. In contrast, a mild pandemic similar to the 1968 epi- sode would go nearly unnoticed and without considerable impact on national healthcare systems and on the global economy. The concern that the world might be in for a revival of the 1918 scenario is based on the observation that the currently spreading H5N1 virus shares disturbing char- acteristics with the virus of the 1918 pandemic (Taubenberger 2005). However, if Global Management 35 H5N1 is to be the candidate virus for the next devastating influenza pandemic, why has it not yet acquired the ability to spread easily between humans? It is true that of the 16 influenza H subtypes, only three (H1, H2 and H3) are known to have caused human pandemics (1918, 1957, 1968, and probably 1889 [Dowdle 2006]), and it has even been hypothesised that H5 viruses are inherently incapable of transmitting efficiently from human to human. Shall we one day dis- cover that H5 viruses are not good for human pandemics, because not all possible subtypes can reassort to form functional human pandemic strains? Apart from stepwise mutations that transform an avian influenza virus into a human influenza virus, reassortment is the second way in which new pandemic viruses are generated. There is some preliminary experimental evidence that reassor- tants of the 1918 virus might be less virulent than the co-ordinated expression of all eight 1918 virus genes (Tumpey 2005). Does that mean that pandemics resulting from reassortment events of a human and an avian virus are milder than pandemics caused by a virus which slowly accumulates mutations in order to “migrate” from water fowl hosts to human hosts? As it is impossible to predict whether the next pandemic will result in ~20 or ~2,000 deaths per 100,000 people, the international community should prepare for the 2,000 figure. Containment Containment and elimination of an emergent pandemic influenza strain at the point of origin has been estimated to be possible by a combination of antiviral prophy- laxis and social distance measures (Ferguson 2005, Longini 2005). If the pandemic cannot be contained early on during an outbreak, rapid intervention might at least delay international spread and gain precious time. However, the opti- mal strategy for the use of stockpiled antiviral drugs is not known, because stopping a nascent influenza pandemic at its source has never before been attempted. Drugs Once a pandemic is under way – and vaccines have not yet become available – na- tional responses depend on the availability of antiviral drugs. As demand for the drug will exceed supply, stockpiling of antiviral drugs, either in the form of cap- sules or the bulk active pharmaceutical ingredient, has been considered a viable option by some governments. After the recent isolation of oseltamivir-resistant isolates in serious H5N1 infection, other 36 Influenza 2006 antiviral agents to which oseltamivir-resistant influenza viruses remain susceptible, should be included in treatment arsenals for influenza A (H5N1) virus infections (de Jong 2005) – in other words: zanamivir. H5N1 isolates obtained from patients in China in 2003 and in one lineage of avian and human H5N1 viruses in Thailand, Vietnam, and Cambodia were resistant to adamantanes (Hayden 2006). However, isolates tested from strains circulating recently in Indonesia, China, Mongolia, Russia, and Turkey appear to be sensitive to amantadine (Hayden 2005). With regard to the economical impact, there is some evidence that even stockpiling of the costly neuraminidase inhibitors might be cost-beneficial for treatment of pa- tients and, if backed by adequate stocks, for short-term postexposure prophylaxis of close contacts (Balicer 2005). When comparing strategies for stockpiling these drugs to treat and prevent influenza in Singapore, the treatment-only strategy had optimal economic benefits: stockpiles of antiviral agents for 40 % of the population would save an estimated 418 lives and $414 million, at a cost of $52. Prophylaxis was economically beneficial in high- risk subpopulations, which account for 78 % of deaths, and in pandemics in which the death rate was > 0. Prophylaxis for pandemics with a 5 % case-fatality rate would save 50,000 lives and $81 billion (Lee 2006). Once a pandemic starts, countries without stockpiles of antiviral drugs will proba- bly be unable to buy new stocks. In this context it has been suggested that govern- ments provide compulsory licensing provisions, permitting generic manufacturers to start producing antivirals locally under domestic patent laws or to import them from generic producers at affordable prices (Lokuge 2006). In Europe, some gov- ernments are trying to build up stocks of the neuraminidase inhibitor oseltamivir for 25 % of the population. The number of treatment doses required to achieve this degree of “coverage” are based on the daily standard treatment course of 75 mg bid for 5 days. At present, the world has a production capacity of about 300 million trivalent influenza vaccines per year, most of which is produced in nine countries (Fedson 2005). Influenza vaccines are currently prepared in fertilised chicken eggs, a process which was developed over 50 years ago (Osterholm 2005). A dream vaccine would provide broad-spectrum protection against all influenza A subtypes (Neirynck 1999, Fiers Global Management 37 2004, De Filette 2006), but these vaccines are experimental and years away from industrial production. Distribution When drug and vaccine supplies are limited, healthcare authorities have to decide who gains access to the drugs and vaccines. Who should receive short-supply vac- cines and antivirals first: young people or the elderly (Simonsen 2004)? If the stan- dard used to measure effectiveness of medical intervention was “numbers of deaths prevented,” then perhaps the elderly should be given priority - assuming they can produce an adequate antibody response to the pandemic vaccine. But if the concern is to minimise the years-of-life-lost, then the vaccine may be better used in young and middle-aged adults (Simonsen 2004). The Australian Government has acknowledged that, in the event of a pandemic, its own stockpile of antivirals will be limited and reserved for those on a confidential rationing list (Lokuge 2006). Experts urge that a framework for determining pri- ority groups be developed prior to the start of a pandemic and that such a scheme should be agreed on beforehand and be flexible enough to adapt to the likely level of disaster at hand (Simonson 2004). In the spring of 1918, a pandemic wave occurred 6 months before the second deadly autumn wave (Olson 2005). The Asian H2N2 influenza virus was charac- terised by early summer, 1957, but significant mortality in the United States did not occur until October – and in 1968, the pandemic wave of mortality in Europe peaked a full year after the pandemic strain first arrived (Simonson 2004). Instead, mortality rates can remain elevated for several years – during which time an effective vaccine would be in high demand. Will it be mild like the last two pandemics of 1968 and 1957, when the new pandemic strain resulted from the reassortment of the pre-existing human strains and an avian influenza strain? Incidence of adamantane resistance among influenza A (H3N2) viruses isolated worldwide from 1994 to 2005: a cause for concern. Adamantane resistance among influ- enza A viruses isolated early during the 2005-2006 influenza season in the United States. Risk of influenza A (H5N1) infection among health care workers exposed to patients with influenza A (H5N1), Hong Kong. High levels of adamantane resistance among influenza A (H3N2) viruses and interim guidelines for use of antiviral agents--United States, 2005-06 influenza sea- son.

The general functions of the cerebellum purchase avalide 162.5mg without a prescription pulse pressure 32, then quality avalide 162.5 mg arrhythmia hypothyroidism, are to produce smooth coordinated movements order avalide 162.5 mg with amex heart attack signs and symptoms, maintain equilibrium order 162.5 mg avalide free shipping heart attack high blood pressure, and sustain normal postures. If you were to look at the outer surface of the cerebrum, the first features you would notice might be its many ridges and grooves. The deepest sulci are called fissures; the longitudinal fissure divides the cerebrum into right and left halves or hemispheres. These halves are almost separate structures except for their lower midportions, which are connected by a structure called the corpus callosum(Figure 7- 5). Two deep sulci subdivide each cerebral hemisphere into four major lobes and each lobe into numerous convolutions. The lobes are named for the bones that lie over them: the frontal lobe, the parietal lobe, the temporal lobe, and the occipital lobe. A thin layer of gray matter, made up of neuron dendrites and cell bodies, composes the surface of the cerebrum. White matter made up of bundles of neuronal fibers (tracts), composes most of the interior of the cerebrum. Within this white matter, however, are a few islands of gray matter known as the basal ganglia, whose functioning is essential for producing automatic movements and postures. The corpus callosum is a broad band of fibres passing between corresponding cortical areas of the two hemispheres. In midsagital section it is the shape of a hook lying horizontally with its bend anteriorly and its point downwards. The pointed portion is known as the rostrum, the bend as genu, the horizontal part as the body and the expanded posterior end as the splenium. The callosum extends laterally into each hemisphere; the anterior fibres pass forwards into the frontal pole and are known as the forceps major, passes backwards into the occipital poles. A bundle of fibres within the lamina , the anterior commissure , unites the piriform areas and the olfactory tracts of the two sides. The fornix (hippocampal) commissure is found on the undersurface of the corpus callosum where the two crura meet and form the fornix. Many form a well defined layer, the internal capsule, between the lentiform nucleus laterally and the thalamus and caudate nucleus medially. Superiorly its fibres fan out as the corona radiate interdigitating with the fibres of the corpus callosum. It possesses an anterior limb (between the caudate nucleus and the lentiform nucleus and crossed by fibres and grey matter uniting the two structures), an apex (the genu) pointing medially, and a posterior limb lying between the thalamus and the lentiform nucleus. The anterior limb carries (a) frontopontine fibres from the frontal lobe to the pons, and (b) fibres from the thalamus (medial and ventro-anterior nuclei) to the frontal lobe. The posterior limb carries from before backwards, (a) pyramidal fibres from the motor cortex which pass to the cranial nerve nuclei (corticospinal fibres), (b) somatosensory fibres passing from thalamus (ventroposterior nucleus) to the postcentral (somatosensory) cortex, (c)temporopontine fibres from the temporal lobe to the pons, (d) the auditory radiations passing from the medial geniculate body under the lentfiform nucleus, to the superior temporal gyrus, (e) the visual radiations 157 Human Anatomy and Physiology passing from the lateral geniculate body around the lateral aspect of the posterior horn of the lateral ventricle to the visual cortex. The course of the fibres is such that many cross the midline (decusate) and end on the opposite (contralteral) side. The motor areas of each hemisphere control the voluntary muscles of the contralateral side of the body and the sensory areas receive information from the contralateral side. Neurons of these structures continually bring impulses to cerebral neurons and continually transmit impulses away from them. If all other neurons were functioning normally and only cerebral neurons were not functioning, here are some of the things that you could not do. Nothing would anger or frighten you, and nothing would bring you joy or 158 Human Anatomy and Physiology sorrow. These terms, then sum up cerebral functions: Consciousness, thinking, memory, sensations, emotions, and willed movements. Figure 7- 6, B, shows the areas of the cerebral cortex essential for willed movements, general sensations, vision, hearing, and normal speech. The visual area of the cortex in the occipital lobe helps you identify and understand specific images. This explains the very specific symptoms associated with an injury to localized areas of the cerebral cortex after a stroke or traumatic injury to the head. Spinal Cord Location of the Spinal Cord In the embryo, the spinal cord occupies the entire spinal canal and so extends down into the tail portion of the vertebral column. However, the column of bone grows much more rapidly than the nerve tissue of the cord, so that eventually the 159 Human Anatomy and Physiology end of the cord no longer reaches the lower part of the spinal canal. This disparity in growth continues to increase; in the adult the cord ends in the region just below the area to which the last rib attaches (between the first and the second lumbar vertebrae. Structure of the Spinal Cord The spinal cord lies within the vertebral canal and extends from the foramen magnum to the level of the second lumbar vertebrae after which a fibrous remnant, the filum terminale, descends to be attached to the back of the coccyx. It is cylindrical in shape, flattened slightly anteroposteriorly, and has cervical and lumbar enlargements where the nerves supplying the upper and lower limb originatethe enlargements lie opposite the lower cervical and lower thoracic vertebrae. Since the spinal cord is shorter than the vertebral canal, the nerves descend with increasing obliquity before leaving the canal through the intervertebral foramina. The collection of lower lumbar, sacral and coccygeal nerves below the spinal cord, with the filum terminale, is known as the cauda equina. The gray matter is so arranged that a column of cells extend up and down dorsally, one on each side; another column is found in the ventral region on each side. These two pairs of columns, called the dorsal and ventral horns, give the gray matter an H-shaped appearance in cross section. In the center of the gray matter is a small channel, central canal that contains cerebrospinal fluid, the liquid that circulates around the brain and spinal cord. The white matter consists of thousands of nerve cell fibers arranged in three areas external to the gray matter on each side. Lippincot Company) Functions of the Spinal Cord The spinal cord is the link between the spinal nerves and the brain. It is also a place where simple responses, known as reflexes can be coordinated even without involving the brain. The functions of the spinal cord may be divided into three categories: 162 Human Anatomy and Physiology 1. Conduction of motor impulses from the brain down through descending tracts to the efferent neurons that supply muscles or glands 3. When you fling out an arm or leg to catch your balance, withdraw from a painful stimulus, or blink to avoid an object approaching your eyes, you are experiencing reflex behaviour. A reflex pathway that passes through the spinal cord alone and does not involve the brain is termed a spinal reflex. If you tap the tendon below the kneecap (the patellar tendon), the muscles of the anterior thigh (quadriceps femoris) contracts, eliciting the knee jerk. Such stretch reflexes may be evoked by appropriate tapping of most large muscles (such as the triceps brachii in the arm and the gastrocnemius in the calf of the leg). Because reflexes occur automatically, they are used in physical examinations to test the condition of the nervous system. The meninges, spinal nerves, and sympathetic trunk are visible in the illustration (Source: Carola, R. Lippincot Company) 165 Human Anatomy and Physiology Figure 7-9 Flow of cerebrospinal fluid (Source: Carola, R. This system includes cranial and spinal nerves that connect the brain and spinal cord, respectively, to peripheral structures such as the skin surface and the skeletal muscles. These connect the brain and spinal cord to various glands in the body and to the cardiac and smooth muscle in the thorax and abdomen. Tracts are located within the brain and also within the spinal cord to conduct impulses to and from the brain. As with muscles, the "wires," or nerve cell fibers in a nerve, are bound together with connective tissue. A few of the cranial nerves contain only motor fibers for conducing impulses away from the brain and are classified as motor, or efferent, nerves.

Prolonged weakness may occur when corticosteroids are used concurrently with non-depolarizing neuromuscular blocking agents order avalide 162.5 mg otc heart attack enrique iglesias s and love. Fast onset and short duration of action with single doses discount 162.5mg avalide with mastercard pulse pressure journal, duration of action prolonged with continued use purchase avalide 162.5mg on line blood pressure upon waking. Epinephrine (Racemic) Post-extubation stridor/croup: Use 1:1000 epinephrine(racemic 2 cheap 162.5 mg avalide with visa heart attack is recognized by a severe pain. Higher doses may be required if administered through a ventilator due to loss of drug in the circuit. Consider supplemental steroids at times of stress if patient has received long-term or frequent bursts of steroid therapy. Prolonged weakness may occur when corticosteroids are used concurrently with non-depolarizing neuromuscular blocking agents. With continuous infusions measure blood glucose q1h initially, adjust dose as required based on blood glucose measurements. Higher doses may be required if administered through a ventilator due to loss of drug in the circuit. Give in water or juice, do mix with fruit juices with high potassium content such as orange juice. Consider supplemental steroids at times of stress if patient has received long-term or frequent bursts of steroid therapy. Prolonged weakness may occur when corticosteroids are used concurrently with non-depolarizing neuromuscular blocking agents. Extrapyramidal reactions occur more commonly in children and may be treated with diphenhydramine. Use with caution in non-ventilated patients due to potential for respiratory depression. To prevent withdrawal, avoid abrupt cessation following high doses or long duration of therapy (> 5 days). Improving the treatment of pain at McMaster Children’s Hospital Morphine is the preferred oral opiate for the treatment of acute pain Morphine has important effectiveness and safety advantages and is preferred over codeine (which historically had been the most commonly used oral opiate at McMaster Children’s Hospital). Codeine is a weak opiate analgesic with minimal intrinsic analgesic activity; it must first be metabolized to morphine which provides most of the analgesic effect. Up to 10% of the population does not effectively metabolize codeine to morphine, resulting in poor pain control. To avoid the unpredictably variable analgesia and potential for toxicity, a simpler approach is to use morphine. Hydromorphone or oxycodone are alternatives for patients who cannot tolerate morphine because of adverse effects. An oral solution is available for doses other than 10 and 20 mg but is very unpalatable and should be given via feeding tube. Hold feeds before and after enteral administration as continuous feeds and formula may decrease bioavailability of oral products. Significantly increased free fraction in patients with hypoalbuminemia may result in underestimation of effective drug concentration and difficulty in interpretation of drug levels and toxicity may occur at “therapeutic” serum levels. Consider supplemental steroids at times of stress if patient has received long-term or frequent bursts of steroid therapy. Prolonged weakness may occur when corticosteroids are used concurrently with non- depolarizing neuromuscular blocking agents. Higher doses may be required if administered through a ventilator due to loss of drug in the circuit. Titrate dose to effect and/or adverse effects (tachycardia, tremor and hypokalemia). For most patients metered dose inhalers with a spacer device are the preferred method of drug delivery. Some patients, particularly those receiving opiates may require higher doses and/or more frequent administration. Use lower doses if there is no significant bleeding and patient will require warfarin in the future. They were developed taking into consideration services provided at different levels within the health system and resources available. These guidelines are intended to standardize care at both tertiary and secondary levels of service delivery across different socio- economic stratifcations of our society. The clinical conditions included in this manual were selected based on facility reports of high volume and high risk conditions treated in each specialty area. The guidelines were developed through extensive consultative work sessions, which included health experts and clinicians from different specialties. The work group brought together current evidence-based knowledge in an effort to provide the highest quality of healthcare to the public. It is my strong hope that the use of these guidelines will greatly contribute to improved diagnosis, management and treatment of patients. And, it is my sincere expectation that service providers will adhere to these guidelines/protocols. The Ministry of Health is grateful for the efforts of all those who contributed in various ways to the development, review and validation of the National Clinical Treatment Guidelines. We would like to thank our colleagues from district, referral and university teaching hospitals, and specialized departments within the Ministry of Health, our partners and private health practitioners. We also thank the Rwanda Professional Societies in their relevant areas of specialty for their contribution and technical review, which enriched the content of this document. Finally, we wish to express thanks to all those who contribute to improving the quality of health care of the Rwanda population. Weak / absent breathing Circulation Cold Hands with any of: Immediate transfer to emergency area: 1. Classifcation of pain severity - Self-reporting: use of number or faces scale - Observational: based on behaviors (crying, shaking, etc. Acute Gastroenteritis Defnition: Gastroenteritis is an infammation of the stomach and intestines that causes diarrhea, vomiting, nausea and other symptoms of digestive upset. Causes - Viral gastroenteritis: Rotaviruses are the most likely cause of infec- tious diarrhea in children under the age of 5 - Bacterial gastroenteritis : Campylobacter, Salmonella or E. Persistent Diarrhea Defnition: Persistent diarrhea is a diarrhea, with or without blood, which begins acutely and lasts for 14 days or longer. Bloody Diarrhea Defnition: Frequent (>3/day) passage of blood and/or mucus in the stool Causes - Amoebic dysentery is the most common serious cause in children - Bacterial infections (e. Peptic Ulcer Disease Defnition: Tis refers to ulceration of gastric or duodenal mucosa that tends to be chronic and/or recurrent Causes - Helicobacter pylori (H. Te symptoms associated with peptic ulcers are not sensitive or specifc and the diferential diagnosis is broad. Causes - Foods : Some mushrooms, polluted drinking water, certain im- properly prepared or handled food - Drugs : Sometimes drugs may be toxic and even deadly when taken in excess e. B It is ofen not possible to distinguish viral pneumonia from disease caused by bacterial pathogens. Wheezing child Defnition: A wheeze is a musical and continuous sound that originates from oscillations in narrowed airways. Wheezing is heard mostly in expira- tion as a result of critical airway obstruction. Causes/ diferential diagnosis - Bronchiolitis - Asthma - Oesophageal foreign bodies - Aspiration Syndrome (gastro-oesophageal refux diseases) 3. Acute Bronchiolitis Defnition: Bronchiolitis is an infammation of the bronchiole tubes due to viral organism resulting in wheezing. If bronchodilators to be used, closely monitor efect as it might worsen respiratory distress. Asthma Defnition: Asthma is a chronic infammatory condition of the lung air- ways resulting in episodic airfow obstruction.

Parasympathetic regulation occurs mainly during the cephalic and gastric phases of gastric secretion buy avalide 162.5 mg with amex blood pressure lab report, when vagal stimulation prompts the secretion of pancreatic juice generic avalide 162.5 mg on line blood pressure screening. Thus avalide 162.5mg lowest price blood pressure 5080, the acidic blood draining from the pancreas neutralizes the alkaline blood draining from the stomach generic 162.5mg avalide with visa blood pressure medication for ptsd, maintaining the pH of the venous blood that flows to the liver. The Gallbladder The gallbladder is 8–10 cm (~3–4 in) long and is nested in a shallow area on the posterior aspect of the right lobe of the liver. This muscular sac stores, concentrates, and, when stimulated, propels the bile into the duodenum via the common bile duct. The fundus is the widest portion and tapers medially into the body, which in turn narrows to become the neck. The cystic duct is 1–2 cm (less than 1 in) long and turns inferiorly as it bridges the neck and hepatic duct. The simple columnar epithelium of the gallbladder mucosa is organized in rugae, similar to those of the stomach. When these fibers contract, the gallbladder’s contents are ejected through the cystic duct and into the bile duct (Figure 23. Visceral peritoneum reflected from the liver capsule holds the gallbladder against the liver and forms the outer coat of the gallbladder. Chemical digestion, on the other hand, is a complex process that reduces food into its chemical building blocks, which are then absorbed to nourish the cells of the body (Figure 23. Chemical Digestion Large food molecules (for example, proteins, lipids, nucleic acids, and starches) must be broken down into subunits that are small enough to be absorbed by the lining of the alimentary canal. Glucose, galactose, and fructose are the three monosaccharides that are commonly consumed and are readily absorbed. Your digestive system is also able to break down the disaccharide sucrose (regular table sugar: glucose + fructose), lactose (milk sugar: glucose + galactose), and maltose (grain sugar: glucose + glucose), and the polysaccharides glycogen and starch (chains of monosaccharides). Your bodies do not produce enzymes that can break down most fibrous polysaccharides, such as cellulose. While indigestible polysaccharides do not provide any nutritional value, they do provide dietary fiber, which helps propel food through the alimentary canal. In the small intestine, pancreatic amylase does the ‘heavy lifting’ for starch and carbohydrate digestion (Figure 23. After amylases break down starch into smaller fragments, the brush border enzyme α-dextrinase starts working on α- dextrin, breaking off one glucose unit at a time. Sucrase splits sucrose into one molecule of fructose and one molecule of glucose; maltase breaks down maltose and maltotriose into two and three glucose molecules, respectively; and lactase breaks down lactose into one molecule of glucose and one molecule of galactose. Protein Digestion Proteins are polymers composed of amino acids linked by peptide bonds to form long chains. Chemical digestion in the small intestine is continued by pancreatic enzymes, including chymotrypsin and trypsin, each of which act on specific bonds in amino acid sequences. At the same time, the cells of the brush border secrete enzymes such as aminopeptidase and dipeptidase, which further break down peptide chains. The most common dietary lipids are triglycerides, which are made up of a glycerol molecule bound to three fatty acid chains. The three lipases responsible for lipid digestion are lingual lipase, gastric lipase, and pancreatic lipase. However, because the pancreas is the only consequential source of lipase, virtually all lipid digestion occurs in the small intestine. The nucleotides produced by this digestion are further broken down by two intestinal brush border enzymes ( nucleosidase and phosphatase) into pentoses, phosphates, and nitrogenous bases, which can be absorbed through the alimentary canal wall. Almost all ingested food, 80 percent of electrolytes, and 90 percent of water are absorbed in the small intestine. Although the entire small intestine is involved in the absorption of water and lipids, most absorption of carbohydrates and proteins occurs in the jejunum. By the time chyme passes from the ileum into the large intestine, it is essentially indigestible food residue (mainly plant fibers like cellulose), some water, and millions of bacteria (Figure 23. Absorption can occur through five mechanisms: (1) active transport, (2) passive diffusion, (3) facilitated diffusion, (4) co- transport (or secondary active transport), and (5) endocytosis. As you will recall from Chapter 3, active transport refers to the movement of a substance across a cell membrane going from an area of lower concentration to an area of higher concentration (up the concentration gradient). Passive diffusion refers to the movement of substances from an area of higher concentration to an area of lower concentration, while facilitated diffusion refers to the movement of substances from an area of higher to an area of lower concentration using a carrier protein in the cell membrane. Co-transport uses the movement of one molecule through the membrane from higher to lower concentration to power the movement of another from lower to higher. Because the cell’s plasma membrane is made up of hydrophobic phospholipids, water-soluble nutrients must use transport This OpenStax book is available for free at http://cnx. Moreover, substances cannot pass between the epithelial cells of the intestinal mucosa because these cells are bound together by tight junctions. Thus, substances can only enter blood capillaries by passing through the apical surfaces of epithelial cells and into the interstitial fluid. Water-soluble nutrients enter the capillary blood in the villi and travel to the liver via the hepatic portal vein. In contrast to the water-soluble nutrients, lipid-soluble nutrients can diffuse through the plasma membrane. Once inside the cell, they are packaged for transport via the base of the cell and then enter the lacteals of the villi to be transported by lymphatic vessels to the systemic circulation via the thoracic duct. Absorption in the Alimentary Canal Breakdown Entry to Food Absorption mechanism Destination products bloodstream Capillary blood in Liver via hepatic Carbohydrates Glucose Co-transport with sodium ions villi portal vein Capillary blood in Liver via hepatic Carbohydrates Galactose Co-transport with sodium ions villi portal vein Capillary blood in Liver via hepatic Carbohydrates Fructose Facilitated diffusion villi portal vein Capillary blood in Liver via hepatic Protein Amino acids Co-transport with sodium ions villi portal vein Systemic Diffusion into intestinal cells, Long-chain fatty circulation via Lipids where they are combined with Lacteals of villi acids lymph entering proteins to create chylomicrons thoracic duct Systemic Diffusion into intestinal cells, circulation via Lipids Monoacylglycerides where they are combined with Lacteals of villi lymph entering proteins to create chylomicrons thoracic duct Short-chain fatty Capillary blood in Liver via hepatic Lipids Simple diffusion acids villi portal vein Capillary blood in Liver via hepatic Lipids Glycerol Simple diffusion villi portal vein Nucleic acid Active transport via membrane Capillary blood in Liver via hepatic Nucleic Acids digestion products carriers villi portal vein Table 23. The small intestine is highly efficient at this, absorbing monosaccharides at an estimated rate of 120 grams per hour. All normally digested dietary carbohydrates are absorbed; indigestible fibers are eliminated in the feces. The monosaccharides glucose and galactose are transported into the epithelial cells by common protein carriers via secondary active transport (that is, co-transport with sodium ions). The monosaccharides leave these cells via facilitated diffusion and enter the capillaries through intercellular clefts. The monosaccharide fructose (which is in fruit) is absorbed and transported by facilitated diffusion alone. The monosaccharides combine with the transport proteins immediately after the disaccharides are broken down. Protein Absorption Active transport mechanisms, primarily in the duodenum and jejunum, absorb most proteins as their breakdown products, amino acids. Short chains of two amino 1136 Chapter 23 | The Digestive System acids (dipeptides) or three amino acids (tripeptides) are also transported actively. However, after they enter the absorptive epithelial cells, they are broken down into their amino acids before leaving the cell and entering the capillary blood via diffusion. Bile salts not only speed up lipid digestion, they are also essential to the absorption of the end products of lipid digestion. Short-chain fatty acids are relatively water soluble and can enter the absorptive cells (enterocytes) directly. The small size of short-chain fatty acids enables them to be absorbed by enterocytes via simple diffusion, and then take the same path as monosaccharides and amino acids into the blood capillary of a villus. The large and hydrophobic long-chain fatty acids and monoacylglycerides are not so easily suspended in the watery intestinal chyme. However, bile salts and lecithin resolve this issue by enclosing them in a micelle, which is a tiny sphere with polar (hydrophilic) ends facing the watery environment and hydrophobic tails turned to the interior, creating a receptive environment for the long-chain fatty acids. Without micelles, lipids would sit on the surface of chyme and never come in contact with the absorptive surfaces of the epithelial cells. The free fatty acids and monoacylglycerides that enter the epithelial cells are reincorporated into triglycerides.

Correlation of events in the cardiac cycle 160 Heart sounds During each cardiac cycle generic 162.5mg avalide with visa arrhythmia access, four heart sounds are generated avalide 162.5 mg on-line pulse pressure fitness. In a normal heart purchase avalide 162.5mg fast delivery prehypertension cdc, however avalide 162.5 mg visa high pulse pressure young age, only the first two (First heart sound and second heart sound) are loud enough to be heard by listening through a stethoscope. When listening to the heart with a stethoscope, one does not hear the opening of the valves, for this is a relatively slowly developing process that makes no noise. However, when the valves close, the vanes of the valves and the surrounding fluids vibrate under the influence of the sudden pressure differentials that develop, giving off sound that travels in all directions through the chest. Two heart sounds are normally clearly Audible per beat, the first and second heart sounds. The heart sounds can be recorded by a microphone placed on the precordium, and a tracing of the sound is called a phonocardiogram. Anatomical location for best hearing the heart sounds th th Mitral valve: The mitral valve is best heard in the mid-clavicular line of the 4 -5 left intercostals space. Types of heart sounds First heart sound (S1) Heard by a stethoscope Frequency: 100Hz Duration: 0. Third heart sounds (S3) Generally, not heard by a stethoscope Recorded by phonocardiogram only one-third to one half of all persons Very low frequency Cause: Rushing of blood into the relaxing ventricles during early diastole Fourth heart sound (S4) or atrial sound Generally not heard by a stethoscope Recorded by phonocardiogram only one-fourth of all persons Very low frequency (about 20 Hz) Cause: Rushing of blood into the aorta and pulmonary artery from the contracting ventricles. A heart murmur is an abnormal sound that consists of a flow noise that is heard before, between, or after the lubb-dupp or that may mask the normal heart sounds. Mitral stenosis: Narrowing of the mitral valve by scar formation or a congenital defect Mitral insufficiency: Back flow or regurgitation of blood from the left ventricle into the atrium due to a damaged mitral valve or ruptured chordae tendinae. Valves of the heart and heart sounds 163 Hemodynamics The science of hemodynamics concerns the relation between blood flow, pressure, and resistance. The heart is a complicated pump, and its behavior is affected by a variety of physical and chemical factors. The blood vessels are multibranched, elastic conduits of continuously varying dimensions. The blood itself is a suspension of red and white corpuscles, platelets, and lipid globules suspended in a colloid solution of proteins. Despite these complicated factors, considerable insight may be gained from understanding the elementary principles of fluid mechanics as they pertain to simpler physical systems. Such principles will be expanded in this chapter to explain the interrelationships among the velocity of blood flow, blood pressure, and dimensions of the various components of the systemic circulation. Blood flows out of the heart (the region of higher pressure) into the closed loop of blood vessels (a region of lower pressure. As blood moves through the system, pressure is lost because of friction between the fluid and the blood vessel walls. The highest pressure in the vessels of the circulatory system is found in the aorta and systemic arteries as they receive blood from the left ventricle. The lowest pressure is found in the venae cavae, just before they empty into the right atrium. Pressure gradient in the blood vessels [The mean blood pressure of the systemic circulation ranges from high 93 mmHg in the arteries to a low of a fewmmH in the venae cavae. For instance, if the pressure at both ends of the segment were 100mmHg, there would be no flow. The flowing equation, derived by the French physician Jean Leonard Marie Poiseuille, shows the relationship between these factors: 8 L η R= —— 4 π r Because the value of 8/π is a constant, the relationship can be rewritten as: L η R ∞ —— 4 r This expression says that resistance increases as the length of the tube and the viscosity of the fluid increase but decreases as the radius increases. How significant are length, viscosity, and radius to blood flow in a normal individual? The length of the systemic circulation is determined by the natomy of the system and is essentially constant. The viscosity of blood is determined by the ratio of red blood cells to plasma and by how much protein is in the plasma. Normally, viscosity is constant, and small changes in either length or viscosity have little effect on resistance. This leaves changes in the radius of the blood vessels as the main contributor to variable resistance in the systemic circulation. Thus, a small change in the radius of a tube will have a large effect on the flow of a liquid through that tube. Thus, veins serve as a blood reservoir, as well as transport passage back to the heart. Smaller veins converge into fewer but larger radii vessels, the velocity of blood flow increases as the blood moves toward the heart. Veins also serve as a large blood reservoir and because their storage capacity, they are called as “capacitance vessels”. As they have abundant collagen tissue, veins have little elasticity in comparison to arteries. Because of these properties, veins are highly distensible or stretchable, and have little elastic recoil. They distend well to accommodate additional amount of blood with only a little rise in venous pressure. Veins with extra amount of blood simply stretch to accommodate without tendency to recoil. When demands for blood are low, the veins can store extra blood as ‘reserve’, because of passive dispensability. As per Frank- Starling’s Law, increased venous return induces an increase in stroke volume of the heart. Therefore, a balance exists between the capacity of the veins, the extent of venous return, and the cardiac output. If more blood remains in the veins instead of being returned to the heart, such storage reduces the effective circulating volume. On the contrary, if venous capacity reduces, more blood returns to the heart, and continues circulating. Venous return refers to the volume of blood entering each atrium per minute from the veins. Since atrial pressure is ‘0’ mm Hg, a small but adequate driving force/pressure promotes the blood flow through large diameter and low resistance veins. Most of these factors influence the pressure gradient between the veins and the heart. Effect of Sympathetic Activity on Venous Return Veins are less muscular, have little muscle tone, but venous smooth muscles are richly supplied with sympathetic adrenergic vasoconstrictor fibers. Sympathetic stimulation produces venous vasoconstriction, elevating venous pressure, which in turn increases the pressure gradient to drive more blood from the veins into the right atrium. Less blood coming from the capillaries remains in the veins but continues to flow toward the heart. It is to be noted that arteriolar vasoconstriction reduces blood flow through these vessels, whereas venoconstriction increases flow through these veins, because of reduced capacitance, squeezes out more of the stored blood in the veins, thus increasing blood flow. This blood pumping action is known as the ‘skeletal muscle pump’, returning extra blood stored in the veins to the heart, during exercise. In exercise, venoconstriction and sympathetic activity also accompanying exercise, further enhances venous return. The skeletal muscle pump also opposes the gravitational effect on the venous system. The vessels below the heart level are subjected to pressure caused by the weight of the column of blood extending from the heart to the level of the vessel.

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