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National and/or local health authorities should be involved in the development of the emergency contingency plan cheap 50mg tenormin amex blood pressure children. Biosafety in the laboratory 393 Contingency plan The contingency plan should provide operational procedures for: • Precautions against natural disasters generic 100mg tenormin free shipping hypertension first line, e tenormin 100 mg arrhythmia dance. The cause of the wound and the organisms involved should be re- ported discount tenormin 50mg mastercard pulse pressure too low, and appropriate and complete medical records kept. Ingestion of potentially infectious material Protective clothing should be removed and medical attention sought. Identification of the material ingested and circumstances of the incident should be reported, and appropriate and complete medical records kept. Potentially infectious aerosol release (outside a biological safety cabinet) All persons should immediately leave the affected area and any exposed persons should be referred to the appropriate center for medical advice. Broken containers and spilled infectious substances Broken containers contaminated with infectious substances and spilled infectious substances should be treated in the same way as biological residue leaks. The cloth or paper towel and the broken material can then be cleared away; glass fragments should be handled with forceps. If dustpans are used to clear away the broken material, they should be autoclaved or placed in an effective disinfec- tant. Cloths, paper towels and swabs used for cleaning up should be placed in a contaminated-waste container. If laboratory forms or other printed or written matter are contaminated, the informa- tion should be copied onto another form and the original discarded into the con- taminated-waste container. Biosafety in the laboratory 395 Breakage of tubes containing potentially infectious material in centrifuges without sealable buckets If a breakage occurs or is suspected while the machine is running, the motor should be switched off and the machine left closed (e. If a breakage is discovered after the machine has stopped, the lid should be replaced immediately and left closed (e. All broken tubes, glass fragments, buckets, trunnions, and the rotor should be placed in a non- corrosive disinfectant known to be active against the organisms concerned. The centrifuge bowl should be swabbed with the same disinfectant, at the appropriate dilution, and then swabbed again, washed with water and dried. Breakage of tubes inside sealable buckets (safety cups) All sealed centrifuge buckets should be loaded and unloaded in a biological safety cabinet. If breakage is suspected within the safety cup, the safety cap should be loosened and the bucket autoclaved. Fire and natural disasters Fire departments and other services should be involved in the development of emergency contingency plans. It is useful to arrange visits from these services to the laboratory to acquaint them with its layout and contents. After a natural disaster, local or national emergency services should be warned of the potential hazards within and/or near laboratory buildings. Occupational transmission of Myco- bacterium tuberculosis to health care workers in a university hospital in Lima, Peru. Laboratory management of agents associ- ated with hantavirus pulmonary syndrome: interim biosafety guidelines. Method for inactivating and fixing unstained smear preparations of Mycobacterium tuberculosis for improved laboratory safety. Increased risk of tuberculosis in health care workers: a retrospective survey at a teaching hospital in Istanbul, Turkey. Survey of mycobacte- riology laboratory practices in an urban area with hyperendemic pulmonary tuberculosis. Increased risk of Mycobacterium tuber- culosis infection related to the occupational exposures of health care workers in Chiang Rai, Thailand. Frequency of nonparenteral occupa- tional exposures to blood and body fluids before and after universal precautions training. Delays in diagnosis and treatment of smear positive tuberculosis and the incidence of tuberculosis in hospital nurses in Blantyre, Malawi. Incidence of tuberculosis, hepatitis, brucellosis, and shig- ellosis in British medical laboratory workers. Factors influencing the transmission and infectivity of Mycobacterium tuberculosis: implications for clinical and public health management. A twenty-five year review of laboratory-acquired human infections at the National Animal Disease Center. The cost-effectiveness of preventing tuberculosis in physicians using tuberculin skin testing or a hypothetical vaccine Arch Intern Med 1997; 157: 1121-7. Transmission of tuberculosis among patients with human immunodeficiency virus at a university hospital in Brazil. A multi-center evaluation of tuberculin skin test positivity and conversion among healthcare workers in Brazilian Hospitals. Sterilization of Mycobacterium tuberculo- sis Erdman samples by antimicrobial fixation in a biosafety level 3 laboratory. Tuberculin skin test conversion among medical students at a teaching hospital in Rio de Janeiro, Brazil. Tuberculin skin testing among healthcare workers in the University of Malaya Medical Centre, Kuala Lumpur, Malaysia. Are univer- sal precautions effective in reducing the number of occupational exposures among health care workers? Its usefulness depends largely on the quality of the sputum specimen and the performance quality of the laboratory. Considerable efforts have been made to improve the sensitivity of sputum smear microscopy (Steingart 2006) and special emphasis will be given in this chapter to these efforts. As most laboratories in 402 Conventional Diagnostic Methods low-resource countries have no access to culturing mycobacteria, alternative simple culturing methods will be discussed, as well as the value of alternative culture media such as blood agar, which is more readily available in most laboratory set- tings than the traditional egg-based media used for mycobacterial isolation. Al- though no multicenter studies have been published to show their efficiency for cultivating mycobacteria, we think that these alternatives should be presented in this chapter, because they may be particularly useful in settings where standard procedures simply cannot be performed due to the absence of laboratory equipment or reagents. Specimens The successful isolation of the pathogen requires that the best specimen be properly collected, promptly transported and carefully processed. Before processing, sputum specimens must be classified at the labo- ratory with regard to their quality, i. In patients who cannot produce it spontaneously, the sputum can be induced by inhalation of hypertonic saline solution. This intervention usually provokes cough and post- bronchoscopy expectorated sputum specimens should be collected because they often provide satisfactory microorganism yields (Sarkar 1980, de Gracia 1988). Gastric lavage fluid must be neutralized with sodium carbonate immediately after collection (100 mg per 5-10 mL specimen). Specimens to be collected for the diagnosis of extrapulmonary disease depend on the site of the disease. The most common specimens received in the laboratory are biopsies, aspirates, pus, urine, and normally sterile body fluids, including cerebro- spinal fluid, synovial, pleural, pericardial, and peritoneal liquid. In tuberculous pleural effusions, the diagnostic value of the pleural biopsy is much higher than that of the fluid and, therefore, is the specimen of choice for the diagnosis (Escudero 1990, Valdez 1998). Specimens should be collected in sterile, leak-proof containers and labeled with the patient’s name and/or identification number before anti-tuberculosis chemotherapy is started. Induced sputum specimens should be labeled as such because they re- semble saliva and may be disregarded at the laboratory. Blood and other specimens prone to coagulate, including bone marrow, synovial, pleural, pericardial and peritoneal fluids, should be collected in tubes containing sulfated polysaccharides or heparin. Lymph nodes, skin lesion material, and tissue biopsy specimens should come without preservatives or fixatives and should not be immersed in saline or any fluid.

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Degenerative diseases of the nervous system : l Damage to the cervical or lumbar vertebrae (disc prolapse) effective tenormin 100mg blood pressure pump. Compression of the nerve order 50 mg tenormin mastercard blood pressure chart on excel, like carpel tunnel syndrome or nerve repair in case of the nerve trauma or nerve transplant surgery 50mg tenormin free shipping 7th hypertension. Basic information : It is very correct to say that before going in for any such surgery absolutely accurate diagnosis is a must discount 100 mg tenormin overnight delivery blood pressure cuffs for sale. It is the duty of the neurosurgeon to inform the patients and his relatives how much the patient is likely to benefit from the surgery. Though in our system the diagnosis and the decision of the need for surgery is mainly in the hands of the neurophysician, still it is necessary that before surgery, the neurophysician and the neurosurgeon discuss the case and if there is any doubt further investigations may be done to confirm the diagnosis, and surgery attempted only after full satisfaction regarding the diagnosis. However, it is not incorrect to say that the brain surgery is comparatively more dangerous than other surgeries. The brain surgeries last approximately for 2 to 4 hours, but sometimes it may also go on for 16 to 20 hours or more. After obtaining a fitness report for surgery from the physician, usually the anesthetist examines the patient to ascertain whether the patient can withstand anesthesia. However, if there is a fear of impending death and not much time is available, neurosurgeons ignore everything and perform emergency surgery in spite of the risk for the sake of humanity. For example, when there is a brain hemorrhage in a road accident and emergency operation is inevitable. If the aim is to reach only the outer membrane of the brain a hole called Burr-hole is drilled in the skull. From well-equipped operation theatres to appropriate operation tables and proper lighting arrangements are essential requirements. During surgery also, monitoring by ultra sound can pinpoint the exact location of the defect deep inside the brain. The stereotaxis instruments help in the biopsy and removal of tumors deep inside the brain and spinal cord. Without opening the skull, through a Burr-hole in the brain, using a needle and an electrode that penetrates deep into the brain, various very complicated diseases can be treated easily. Vaga1 stimulation is also a similar minor procedure in which microelectrode and a stimulator can be used to stop the electrical storms taking place in the brain with the help of computerized methods. Apart from this, if necessary major surgeries like lobectomy, hemispherectomy, corpus callosotomy etc can be done. Various other surgeries like the transaction surgery where an impulse can be prevented from passing from one neuron to another can also be done. Radio Frequency Lesion generator : This technique has been proved very effective in Trigeminal Neuralgia and other such painful diseases and also in movement disorders like Parkinson’s disease. As the name suggests, relief is obtained in the disease by using radio frequency current to block the functioning of a nerve or to cauterize it. Gamma knife and Linear Accelerator : This method is becoming increasingly popular to treat tumors or other such diseases without resorting to surgery. Endoscopic Neurosurgery : This is also a kind of minimally invasive surgery, which means that without opening the brain completely, the diseases located deep inside the brain especially tumors or aneurysms are tackled. This reduces the risk of surgery considerably but conducting the surgery from a very small opening with a microscope requires profound experience. Now-a-days our surgeons have gained expertise in conducting “Awake Craniotomy” in which no anesthesia is used and the patient is operated upon in a fully conscious state. When the disease has spread beyond limit, surgeons just remove a part of it and feel the satisfaction of having helped the patient. When it is not possible to remove the entire tumor and there is a danger that the patient may die on the operation table or surgery may paralyze a major portion of the body, it makes sense for the doctor to excise some part of the tumor so that the patient can feel better and survive a little longer. Functional Neurosurgery : In ‘this there is not much h of : excision involved but the nonfunctional parts are made to function in a different way. If necessary grafting of new cells or putting a stimulator in the brain, injecting chemicals or drugs or making newer paths through small openings can be done. In major cities like Mumbai, Delhi all types of surgeries are available and the world-renowned doctors having the best of education and expertise are available to serve the patients, and that is the pride of our nation. In majority of operations the risk factor is 2% to 4% at good centres, but if the patient is aged and suffers from diabetes or heart disease or blood pressure or the operation has had to be done in an emergency, the risk may go up to 10% to 20%. If the surgeon or the anesthetist feels that the risk is high, it is advisable to avoid surgery and treat the patient with medicines only. If the relatives of the patient insist on taking a chance, the surgeon can perform surgery on consent. Like in brain attack, if there is hemorrhage with a lot of swelling and if the prognosis is very bad, the skull can be opened so that the brain can swell outside or attempts are made to suck out the hemorrhage, so the chances of saving the patient’s life compared to certain death can be calculated as S to 25%. After being discharged, special attention is given to the fact that the patient becomes ambulatory as soon as possible. Physiotherapy is started during hospitalization itself and is continued even after the patient goes home till he gets completely cured. After the surgery, the follow up by neurosurgeon and neurophysician are again required for the rest of the treatment. Therefore, the best option is to discuss all the aspects of the surgery frankly before and after the surgery and the doctor should also give a clear picture right from the beginning. It requires the teamwork of the neurophysician, the neurosurgeon, the physiotherapist, the occupational therapist and the physician. It should be realized that the expenditure in each case differs according to the case The kind of disease, severity, necessity of an emergency surgery, experience of the surgeon, the place where the surgery is done, how well equipped is the hospital, the risk of anesthesia (like in the aged patients as well in diabetic and heart patients the risk is more) and many other such factors determine the cost. In foreign countries most of the expenses are being borne by the insurance agencies, so the patient or the doctors do not have to waste time and energy on these matters. We have seen in the previous chapter that many neurological disorders are very difficult and their treatment has to be continued for a long period like 6-12 months or in some diseases even lifelong. The purpose of this chapter is to impart correct information regarding the effects as well as the side-effects of these drugs, but here it needs to be stressed that taking any medicine without consulting the doctor is very dangerous and so all these medicines should be taken under the supervision of the doctor. Self-medication should be avoided Steroids : Steroids are used in some important, stubborn and acute diseases of neurology. But if these drugs are taken inappropriately, in wrong doses without a doctor’s supervision for a long time, many serious problems can occur. The worst part is that these drugs have frequently been misused and abused instead of being appropriately used. Steroids play the major role in regulating the functions of the various glands, organs and systems of the body, development of immunity and fighting against stress. So, it can be comprehended that in the serious diseases occurring due to the defi of steroids, it is imperative to give synthetically prepared steroids. In neurology, appropriate use of steroids can give desired results in diseases ranging from low blood pressure to myasthenic crisis, cluster headaches to brain edema etc. In some neuropathies, demyelinating diseases (multiple sclerosis), brain tumor, polymyositis, some cases of T. Acidity (burning sensation in stomach and chest) and ulcer formation or worsening of previous ulcers in the stomach. Bloating of the body, excessive weight gain, and accumulation of fat on the face, stomach and back of the neck 8. However, in some diseases very less result is seen on short-term administration of steroids and, therefore, they may have to be continued for a long period. In order to prevent the side effects of steroids (in long-term steroids course), the doctors regularly prescribe calcium, potassium, vitamins and diuretics (to prevent edema) in proper doses. In addition to this, many medicines are used for a long period of time in neurological cases like epilepsy (fit), headaches, parkinsonism etc. Diphenyl Hydantoin In rare cases this medicine can cause a serious allergic reaction, known as Steven’s Johnson syndrome which starts with erythema on skin and fever endangering life. The common side-effects of this drug are inflammation of the gums, regression of the beauty and softness of the face, unwanted hair growth, decline in memory, enlarged lymphnodes in the neck, damage to the small brain (cerebellum), or minor problems of the nerves. Therefore, the patients using this drug should regularly get their blood tested for various blood cell levels every three to four months.

As the mechanism thus increasing the amount of norepinephrine in the of action involves the release of intracellular catechola- synaptic space discount tenormin 50mg otc high blood pressure medication and sperm quality. Ephedrine is (mostly) an “indirect- mines discount 50mg tenormin with amex blood pressure 8660, there is an unpredictable effect in patients with acting” catecholamine because it doesn’t act at the depleted endogenous catecholamines generic tenormin 50 mg heart attack jaw. Used in infiltration anesthesia buy 100mg tenormin free shipping arrhythmia test questions, spinal due to incorrect dosing or inadvertent intravascular in- and epidural anesthesia and other regional anesthesia jection then the symptoms manifest firstly in the central techniques. Premonitory signs and symptoms are pe- Dose rioral numbness, metallic taste, tinnitus, restlessness , diz- Maximum 2mg/kg without epinephrine ziness and tremors. Administration of ben- Safe dose depends on where and how it is being adminis- zodiazepines will increase the seizure threshold. For example, absorption from intercostal admini- stration is greater than for administration in adipose tis- High intravascular concentrations of local anesthetics sue. Onset Infiltration: 2-10 minutes Epidural: 10-30 minutes Spinal: <5 minutes Duration Infiltration: 2-5 hours Epidural and spinal: up to 3. Lidocaine is rarely used in spinal Local anesthetics should not have systemic effects if anesthesia due to associated nerve irritation. If high plasma levels are achieved occasionally used in the treatment of ventricular arrhyth- due to incorrect dosing or inadvertent intravascular in- mias. Premonitory signs and symptoms are pe- Dose Anesthetic: rioral numbness, metallic taste, tinnitus, restlessness , diz- Maximum 4 mg/kg without epinephrine ziness and tremors. These side effects tis, allergic reactions and drug-induced extrapyramidal reflect its anticholinergic activity, which is additive reactions. The antiemetic effects is related to central anticholinergic effect as well as histamine an- tagonism in the vestibular system in the brain. It is a direct skeletal muscle relaxant which acts at the muscle cellular level, possibly at the ryanodine recep- tor. Special “guns” have been devised to speed the preparation of dantrolene so as to minimize any delay in administration in the ur- gent situation. Medical / psychiatric co-morbidities and treatment strategies for these disorders used with opiate addicts 4. Key issues in engaging opiate addicts into treatment with low threshold approaches 7 7 Opioids Definition Opioids are natural derivatives of opium or synthetic psychoactive substances that have effects similar to morphine or are capable of converting into a drug having such effects. Europe 9 Notes Proportions of heroin abuse vary by region: -Almost all of opiate consumers in Africa are reportedly abusing heroin. Heroin (diacetylmorphine), a semi-synthetic substance, is the result of a chemical process that combines opium with two additional molecules. Opium contains around 1–15% morphine, 1–2% codeine, and 75–80% substances which have little or no pharmacological activity (Victoria Police, 2001). Between 1 in 4 to1 in 3 regular users develop dependence z Development of heroin dependence usually requires regular use over months (or longer, when use is more irregular) 14 14 The revolving door z Heroin dependence is a chronic, relapsing disorder. Long-term follow-up of those entering treatment suggests: –Only 10% of heroin users will become and remain abstinent in the first year after treatment –Approximately 2%–3 % of people who use heroin will achieve abstinence and remain abstinent in each subsequent year. These entirely artificial drugs have been synthesised without commencing the process with a naturally occurring opioid. Commonly used opioid-based preparations include: – heroin/homebake – morphine/morphine-based medications such as Pethidine – codeine phosphate and codeine based preparations, e. Victoria Police 2002, Custodial Drug Guide: Medical Management of People in Custody with Alcohol and Drug Problems, Custodial Medicine Unit, Victoria Police, Mornington, Victoria. It is also believed that there are several other subtypes whose characteristics are yet to be determined. There are also four groups of endogenous peptides (enkephalins, endorphins, dynorphins, and endomorphins) produced by peptidases that cleave inactive precursor peptides. Sources: Victoria Police 2002, Custodial Drug Guide: Medical Management of People in Custody with Alcohol and Drug Problems, Custodial Medicine Unit, Victoria Police, Mornington, Victoria. All prescription opioids produce morphine-like effects but rather than removing pain, they alter perceptions of the pain so that it is more tolerable and less aversive. Opioids produce analgesia and euphoria, decrease muscle tone, slow movement of the digestive tract, may alter hormonal balance and have a role in regulating immune function. Inhibition of the respiratory system and potential for overdose occur due to the brainstem response to carbon dioxide Opioids are distinguished from sedative hypnotics through their powerful analgesic, anti-diarrhoeal, and cough suppressant properties. Although most are metabolised by oxidation, morphine and buprenorphine are conjugated with glucuronic acid in the liver. As morphine is rapidly metabolised by the liver after oral administration, only a small amount reaches systemic circulation (Young et al. Analgesia: pain is not removed but perception of pain altered so that the experience is no longer aversive. Suppression of cough reflex, nausea and vomiting: opioids stimulate the chemoreceptor trigger zone in medulla. The euphoric effects of opioids, especially when injected, can be highly reinforcing to vulnerable individuals. Effects such as euphoria, flushing and the abdominal ‘buzz’ (described by many as akin to orgasm) are specific to recreational experiences and are not generally seen when opioids are used in clinical situations. All opioids exert a morphine-like effect, producing drowsiness, clouding of sensorium and perception, mood changes (usually euphoria or contentment), analgesia and respiratory depression. At high doses, the muscle tone of the large trunk and intercostal muscles may increase (tighten), hence further impairing breathing. Opioids increase muscle tone, specifically affecting the Sphincter of Oddi (increasing the muscle tone). Tolerance to opioids develops rapidly, commencing with the first dose and involves: – down-regulation – reduced number of receptors – desensitisation – diminished response to receptor action. Narcotic bowel syndrome • Characterised by bloating, vague abdominal discomfort • Physical examination and investigations are negative though patients may have a dilated bowel (with no obstruction) • Intervention – taper to discontinue the drug use. Medication induced headaches • This condition generally refers to patients who are not regular heroin users but who are receiving mixed opioid/non-opioid analgesics such as paracetamol with codeine for management of migraine. Patients may report increased headache frequency since commencing the use of opioid-based medications which stop on cessation of analgesia. It is not unusual for patients to experience depression or sadness in the face of significant change and take time to adjust to a different lifestyle. Ongoing assessment is important to ensure adequate support is provided and for detecting the possible emergence of any mental health problems. Victoria Police 2002, Custodial Drug Guide: Medical Management of People in Custody with Alcohol and Drug Problems, Custodial Medicine Unit, Victoria Police, Mornington, Victoria. Urinalysis: •may be valuable in confirming drug use history, although this is an expensive process and the results are not immediately available •indicates evidence of recent use but does not identify dependence, nor does it indicate problem areas •does little to assist in building rapport with patient. With methadone, withdrawal may not commence for 2–3 days after most recent dose and last for up to 3 weeks. Despite depictions of heroin withdrawal in popular culture, opioid withdrawal is rarely, and is unlikely to be, fatal. Withdrawal (and the culture or lifestyle associated with use, or withdrawal from that lifestyle) may precipitate dysthymia or depression. Despite potential severity, opioid withdrawal does not present a risk for fatality, except in the neonate or when other significant medical conditions are present. Victoria Police 2002, Custodial Drug Guide: Medical Management of People in Custody with Alcohol and Drug Problems, Custodial Medicine Unit, Victoria Police, Mornington, Victoria, pp. A Manual for Doctors to Assist in the Treatment of Patients Withdrawing from Alcohol and Other Drugs, Next Step Specialist Drug and Alcohol Services, Mt Lawley, Perth, Western Australia, www.

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The first is the anagen phase generic 100 mg tenormin fast delivery hypertension xray, during which cells divide rapidly at the root of the hair effective tenormin 100mg arteria obstruida en el corazon, pushing the hair shaft up and out buy 50mg tenormin free shipping blood pressure 7550. The catagen phase lasts only 2 to 3 weeks buy 100mg tenormin overnight delivery blood pressure medication what does it do, and marks a transition from the hair follicle’s active growth. The basal cells in the hair matrix then produce a new hair follicle, which pushes the old hair out as the growth cycle repeats itself. Hair loss occurs if there is more hair shed than what is replaced and can happen due to hormonal or dietary changes. Hair Color Similar to the skin, hair gets its color from the pigment melanin, produced by melanocytes in the hair papilla. Different hair color results from differences in the type of melanin, which is genetically determined. As a person ages, the melanin production decreases, and hair tends to lose its color and becomes gray and/or white. Nails The nail bed is a specialized structure of the epidermis that is found at the tips of our fingers and toes. The nail body is formed on the nail bed, and protects the tips of our fingers and toes as they are the farthest extremities and the parts of the body that experience the maximum mechanical stress (Figure 5. The nail body forms at the nail root, which has a matrix of proliferating cells from the stratum basale that enables the nail to grow continuously. The nail fold that meets the proximal end of the nail body forms the nail cuticle, also called the eponychium. The nail bed is rich in blood vessels, making it appear pink, except at the base, where a thick layer of epithelium over the nail matrix forms a crescent-shaped region called the lunula (the “little moon”). Sweat glands develop from epidermal projections into the dermis and are classified as merocrine glands; that is, the secretions are excreted by exocytosis through a duct without affecting the cells of the gland. These glands are found all over the skin’s surface, but are especially abundant on the palms of the hand, the soles of the feet, and the forehead (Figure 5. They are coiled glands lying deep in the dermis, with the duct rising up to a pore on the skin surface, where the sweat is released. This type of sweat, released by exocytosis, is hypotonic and composed mostly of water, with some salt, antibodies, traces of metabolic waste, and dermicidin, an antimicrobial peptide. Eccrine glands are a primary component of thermoregulation in humans and thus help to maintain homeostasis. An apocrine sweat gland is usually associated with hair follicles in densely hairy areas, such as armpits and genital regions. Apocrine sweat glands are larger than eccrine sweat glands and lie deeper in the dermis, sometimes even reaching the hypodermis, with the duct normally emptying into the hair follicle. In addition to water and salts, apocrine sweat includes organic compounds that make the sweat thicker and subject to bacterial decomposition and subsequent smell. The release of this sweat is under both nervous and hormonal control, and plays a role in the poorly understood human pheromone response. Most commercial antiperspirants use an aluminum-based compound as their primary active ingredient to stop sweat. When the antiperspirant enters the sweat gland duct, the aluminum-based compounds precipitate due to a change in pH and form a physical block in the duct, which prevents sweat from coming out of the pore. Sebaceous Glands A sebaceous gland is a type of oil gland that is found all over the body and helps to lubricate and waterproof the skin and hair. They generate and excrete sebum, a mixture of lipids, onto the skin surface, thereby naturally lubricating the dry and dead layer of keratinized cells of the stratum corneum, keeping it pliable. The fatty acids of sebum also have antibacterial properties, and prevent water loss from the skin in low-humidity environments. The underlying hypodermis has important roles in storing fats, forming a “cushion” over underlying structures, and providing insulation from cold temperatures. It acts as a protective barrier against water loss, due to the presence of layers of keratin and glycolipids in the stratum corneum. It also is the first line of defense against abrasive activity due to contact with grit, microbes, or harmful chemicals. Sweat excreted from sweat glands deters microbes from over-colonizing the skin surface by generating dermicidin, which has antibiotic properties. It provides a barrier between your vital, life-sustaining organs and the influence of outside elements that could potentially damage them. The skin can be breached when a child skins a knee or an adult has blood drawn—one is accidental and the other medically necessary. However, you also breach this barrier when you choose to “accessorize” your skin with a tattoo or body piercing. Because the needles involved in producing body art and piercings must penetrate the skin, there are dangers associated with the practice. These include allergic reactions; skin infections; blood-borne diseases, such as tetanus, hepatitis C, and hepatitis D; and the growth of scar tissue. Despite the risk, the practice of piercing the skin for decorative purposes has become increasingly popular. According to the American Academy of Dermatology, 24 percent of people from ages 18 to 50 have a tattoo. Sensory Function The fact that you can feel an ant crawling on your skin, allowing you to flick it off before it bites, is because the skin, and especially the hairs projecting from hair follicles in the skin, can sense changes in the environment. The hair root plexus surrounding the base of the hair follicle senses a disturbance, and then transmits the information to the central nervous system (brain and spinal cord), which can then respond by activating the skeletal muscles of your eyes to see the ant and the skeletal muscles of the body to act against the ant. The skin acts as a sense organ because the epidermis, dermis, and the hypodermis contain specialized sensory nerve structures that detect touch, surface temperature, and pain. These receptors are more concentrated on the tips of the fingers, which are most sensitive to touch, especially the Meissner corpuscle (tactile corpuscle) (Figure 5. In addition to these specialized receptors, there are sensory nerves connected to each hair follicle, pain and temperature receptors scattered throughout the skin, and motor nerves innervate the arrector pili muscles and glands. The sympathetic nervous system is continuously monitoring body temperature and initiating appropriate motor responses. Recall that sweat glands, accessory structures to the skin, secrete water, salt, and other substances to cool the body when it becomes warm. Even when the body does not appear to be noticeably sweating, approximately 500 mL of sweat (insensible perspiration) are secreted a day. In addition to sweating, arterioles in the dermis dilate so that excess heat carried by the blood can dissipate through the skin and into the surrounding environment (Figure 5. In contrast, the dermal blood vessels constrict to minimize heat loss in response to low temperatures (b). Although the temperature of the skin drops as a result, passive heat loss is prevented, and internal organs and structures remain warm. If the temperature of the skin drops too much (such as environmental temperatures below freezing), the conservation of body core heat can result in the skin actually freezing, a condition called frostbite. Among these changes are reductions in cell division, metabolic activity, blood circulation, hormonal levels, and muscle strength (Figure 5. In the skin, these changes are reflected in decreased mitosis in the stratum basale, leading to a thinner epidermis. The dermis, which is responsible for the elasticity and resilience of the skin, exhibits a reduced ability to regenerate, which leads to slower wound healing. The hypodermis, with its fat stores, loses structure due to the reduction and redistribution of fat, which in turn contributes to the thinning and sagging of skin. Other cells in the skin, such as melanocytes and dendritic cells, also become less active, leading to a paler skin tone and lowered immunity. Wrinkling of the skin occurs due to breakdown of its structure, which results from decreased collagen and elastin production in the dermis, weakening of muscles lying under the skin, and the inability of the skin to retain adequate moisture.

The Pennsylvania governor cheap tenormin 50 mg on line heart attack 4sh, the Pennsylvania State University College of Medicine tenormin 100 mg amex blood pressure 40, the Pennsylvania Children’s Partnership buy tenormin 50 mg pulse pressure readings, and several other state and regional child welfare agencies strongly support the program (Dias et al cheap 50mg tenormin with mastercard blood pressure medication and pregnancy. With academic, governmental and community endorsement, it now represents a multi-institutional partnership that embraces the concepts of collaboration and co-operation in reducing child maltreatment. Program materials were translated into several languages including Hmong, Russian, Spanish, and Somali, to cater to the ethnic diversity of the target population. People in local correctional facilities, public schools, home visitor programs, and teen parenting agencies also receive information about shaken baby syndrome. Recently, incarcerated women have participated in the design, assembly and distribution of program materials to Ohio hospitals. This unique initiative aims to empower the women to make a positive contribution to society and to educate them about shaken baby syndrome, while simultaneously creating a supply of program materials. The hospital-based program is currently operating in 32 hospitals, and the founding hospital has a 97% commitment statement return rate (Lisa Carroll, personal communication, August, 2005). Some hospitals have placed the provision of program materials on the hospital discharge nursing summary sheet. On- going funding for the Ohio program has come from state agencies, the Ohio Attorney General, and private foundations. Because there is no mandate for the state-wide provision of educational 35 36 materials in Ohio, program leaders have focused on empowering parents and members of the local community to take an active role in preventing shaken baby syndrome. To date, there is no mechanism in place to track the impact of these initiatives on the Ohio incidence rate of shaken baby syndrome. It is hoped that an on-going partnership between public and private funding sources will ensure the future sustainability of the program. At every infant’s first visit to pediatric care providers, parents are given advice regarding how to cope with infant crying and are reminded of the dangers of infant shaking (Dias et al. It is hoped that the repeated information will help parents responsibly cope with the stresses of infant care and, ultimately, further reduce the incidence rate of shaken baby syndrome. Both states do not have legislation mandating the provision of program materials, and have encountered difficulties in establishing the baseline incidence rate of shaken baby syndrome. While information about shaken baby syndrome is likely valuable in any context, the lack of program centralization in the birthing hospitals and the omission of the commitment statement significantly alters the nature of the program and limits the capacity for evaluation. In Ontario, Canada, the University of Toronto and the Ontario Neurotrauma Foundation are collaborating to implement the Shaken Baby Syndrome Parent Education Program in hospitals in Sudbury, North Bay, and the Greater Toronto Area. Monitoring the regional incidence rates of shaken baby syndrome is expected to be challenging, but it is hoped that collaboration with public health departments will facilitate the research component of the program. The program is fully operational in several states and is expanding into other areas of the United States and Canada. It has been well-received by the public, the media, health care workers, governments, and public and private institutions and funding agencies. It has the potential to be 37 38 successfully implemented in regions with varying demographic characteristics, provided that the necessary financial and professional resources are available. Remarkably, the original program goals developed by Dias in 1998 are still intact: 1) the program is universally applied, operating in all maternity care hospitals within a given region, 2) information is consistently provided to parents at the same point in time – in the hospital, following the birth of their child, 3) the participation of fathers and father figures is actively sought, even though program materials are presented to both parents, 4) the commitment statements engage parents in their own educational process, and instill in them a sense of responsibility and commitment toward preventing shaken baby syndrome, 5) the dissemination of program materials is effectively tracked using the returned commitment statements, 6) the seven-month follow-up calls provide research data on parents’ recollection and retention of program information, and 7) clearly defined, quantifiable outcome measures enable staff to assess the effectiveness of the program (Dias et al. Cost-benefit analyses have strongly indicated that the costs of preventing shaken baby syndrome are far less than the costs of treating shaken infants. The program expenditures could be reclaimed if the average cost of caring for injured infants was $21,925 per child per year, which is well within published estimates (Dias et al. Although the International Classification of Diseases finally introduced a specific code for shaken infant syndrome in 1996, it is largely underutilized and unknown, resulting in a persistent underestimation of the magnitude of the problem (Shaken Baby Syndrome Surveillance In Massachusetts. The political and financial will to develop state/province-wide or national centralized databases for tracking cases of shaken baby syndrome is still largely absent, and the participation of public health departments in case-tracking has also been underutilized. Until centralized surveillance systems are functional, regions aiming to effectively prevent shaken baby syndrome will continue to encounter incredible difficulties in establishing baseline incidence rates of inflicted infant head injuries. Inadequate financial support has also been a critical factor limiting program dissemination to other regions (Dias et al. States like Pennsylvania are at risk of being in a future position where program provision is required by law but funding is inadequate to support program operations. As evidence for the program’s effectiveness mounts, it is hoped that the challenges of obtaining financial backing will diminish. Increased participation from private health insurers appears to be a realistic hope for the near future, with the Utah and New York programs currently benefiting from this innovative partnership. Health insurance companies stand to save a significant amount 39 40 of money by funding the program, and it is hoped that they continue to recognize the financial and social value of their support in the future. Two key factors have been identified for successful program replication: 1) finding capable project co-ordinators, and 2) maintaining a manageable pace of program implementation. Regions that have encountered the greatest difficulties in program implementation have either lacked devoted, experienced project co-ordinators or have attempted to introduce the program at an unsustainable pace. The success of the original program has been enthusiastically embraced but the replication process has been partial, undermining the evidence for the program. Many new regions adopting the program have failed to incorporate a research component into the planning, start-up and maintenance program phases. Rather than rest on the laurels of the success in Upstate New York, program co-ordinators must persist in effectively educating parents about shaken baby syndrome by assessing the value of their innovations in terms of its impact on the incidence rate of this tragic form of abuse. The program is unique in its proven effectiveness and can only evolve into an optimally transportable, efficacious entity with a continuous commitment to evaluation as well as innovation. Barr and Rivara are undertaking the first randomized controlled trial in the primary prevention of shaken baby syndrome. Their study will run from 2005-2007 and will compare the effectiveness of delivering parent education materials in various health care settings including hospital delivery wards, pediatricians’ offices, and prenatal classes (U. Barr’s approach to prevention focuses on the normalization of persistent infant crying and on encouraging parents to develop effective coping strategies to deal with the feelings of low self-efficacy, depression, and frustration that can be associated with infant crying. The first phase of the study seeks to measure the program’s efficacy in terms of parent knowledge and attitudes about infant shaking, sense of parenting competence, and maternal depression. A second study phase will seek to track the program’s impact on the incidence rate of shaken baby syndrome. It is encouraging to note a progression toward increasingly evidence-based endeavours in the field of shaken baby syndrome prevention, especially in the five years following the success of Dias’ best practice program. Having a variety of published studies that embody different approaches to primary prevention in the field of shaken baby syndrome will certainly stimulate future research and raise the bar on the standard of prevention work currently being conducted. Given the success of the Upstate New York Shaken Baby Syndrome Parent Education Program, it is anticipated that regions across North America will continue to embrace and deliver this 41 42 highly effective primary prevention program to all new parents. Its goal to reduce child abuse is universally applauded, and the fact that it has produced valid, quantifiable results is immensely promising. If the efficacy of the program can be established in a variety of social venues, it is both desirable and possible for this program to capture the attention of health departments and professionals around the world and be incorporated into routine postpartum hospital visits. Clearly, the evidence suggests that it is possible to prevent this devastating form of child abuse using a simple, comprehensive parent education program. The infant shaken impact syndrome: A parent education campaign in Upstate New York (first year summary). Preventing abusive head trauma among infants and young children: A hospital-based parent education program. A review of social factors in the investigation and assessment of non-accidental head injury to children. Preventing shaken baby syndrome in Utah: Replication and evaluation of a promising 45 46 program to reduce the incidence and associated medical cost of shaken babies. Testimony concerning the establishment of a statewide shaken baby syndrome education and prevention program. Persistent crying in early infancy: A non-trivial condition of risk for the developing mother-infant relationship. Factors affecting clinical referral of young children with a subdural hemorrhage to child protection agencies.

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Most 50 mg tenormin amex blood pressure medication how long to take effect, but not all purchase 100mg tenormin amex arteriogram cpt code, controlled studies show a protective effect of hand washing in reducing upper respiratory tract infections purchase 50mg tenormin with mastercard blood pressure line chart; most of the infec- tions studied were likely viral buy tenormin 50mg online arrhythmia recognition, but only a small percentage were due to influenza (Fasley 1999). Risk Communication A risk communication strategy, flexible enough to increase its intensity during dif- ferent pandemic phases, should be established. It is advisable to identify an offi- cial spokesperson during the interpandemic phase who will continue to carry out that task during subsequent phases of the pandemic. Conclusions A major influenza pandemic will have devastating consequences, with uncalculable risks for human health, global economy and political and social stability in most countries. Robust financial resources and a good medical infrastructure may help alleviate some of these consequences; however, developing countries are likely to be faced with insufficient or non-existent stocks of antiviral drugs, and without an appropriate vaccine. In some African, Latin American and Southeast Asian countries, people sleep in the same places as poultry. In Southeast Asia and beyond, markets with live poultry pose a risk of human transmission (Webster 2004). Reducing human exposure re- quires education about handling poultry and a fundamental change in cultural atti- tudes towards human-animal interactions in many parts of the world (World Report 2005). Simple precautionary measures for food preparation, poultry handling, and avoidance of contaminated water are essential until effective human vaccines for H5N1 viruses become available (Hayden 2005). Therefore, pandemic preparedness in developing countries should consider funds for public education to generate cul- tural changes and improvements in hygiene. If transmission of a new pandemic strain begins in human beings, the speed at which influenza spreads will depend on how early it is detected, and how fast the international community can mobilise and deliver assistance, including providing antiviral drugs for prophylactic use. Therefore, in addition to a national prepared- ness plan, governments should actively seek international collaborations with neighbouring countries (Ho 2004). Many countries are too poor to buy drug stockpiles and have no capacity for manufacturing vaccine or generic versions of drugs (World Report 2005). West- ern nations are stockpiling antiviral drugs and developing vaccines, leaving poor and middle-income countries to worry that they will not have access to these poten- tial lifesavers. At this meeting, none of the proposals directly addressed the question of equitable access to medicines and vaccines should a pandemic occur (Enserink 2005). Pandemics do not have fron- tiers, so international co-operation and equitable distribution of resources should start as soon as possible. Evaluation of a handwashing intervention to reduce respiratory illness rates in senior day-care centers. Neuraminidase sequence analysis and susceptibilities of influenza virus clinical isolates to zanamivir and oseltamivir. Neuraminidase inhibitor-resistant influenza viruses may differ substantially in fitness and transmissibility. Influenza viruses have been with mankind for at least 300 years, causing epidemics every few years and pandemics every few decades. Today, we have the capability to produce 300 million doses of trivalent vaccine per year – enough for current epidemics in the Western world, but insufficient for coping with a pandemic (Fedson 2005). With regard to the present fear of an imminent influenza pandemic, “Vaccination and the use of antiviral drugs are two of the most important response measures for reducing morbidity and mortality during a pan- demic. Vaccine Development History The concept of vaccination was practiced in ancient China, where pus from small- pox patients was inoculated onto healthy people in order to prevent naturally ac- th quired smallpox. This concept was introduced into Europe in the early 18 century, and in 1796, Edward Jenner did his first human experiments using cowpox to vac- cinate (vacca is Latin for cow) against smallpox. Greater advances were made in vacci- nology and immunology, and vaccines became safer and mass-produced. Today, thanks to the advances of molecular technology, we are on the verge of making influenza vaccines through the genetic manipulation of influenza genes (Couch 1997, Hilleman 2002). Yearly Vaccine Production All vaccines in general use today are derived from viruses grown in hens’ eggs, and contain 15 µg of antigen from each of the three strains selected for that year’s vac- cine – two influenza A strains (H1N1 and H3N2) and one influenza B strain. From 128 Vaccines the selection of the strains to be used in the vaccine, all the way to the final vaccine, is a lengthy process that may take up to 6–8 months. This decision is made each year in February for the following northern hemisphere winter and September for the following southern hemisphere winter. One can see that the H1N1 influenza A in the vaccine still represents the circulating strain, while the H3N2 virus has changed over time. As a matter of fact, the rate of vaccine failure was unusually high during the winter season 2004/2005. If the strain Vaccine Development 129 chosen to be represented in the vaccine is the same as that used in the previous vac- cine, the process is faster. This new virus is then incubated in embryonated hens’ eggs for 2-3 days, after which the allantoic fluid is harvested, and the virus particles are centrifuged in a solution of increasing density to concentrate and purify them at a specific density. Finally, the concentrations are standardized by the amount of hemagglutination that occurs (Hilleman 2002, Potter 2004, Treanor 2004). After this, the three strains – two influenza A strains and one influenza B strain, which were all pro- duced separately – are combined into one vaccine, their content verified, and packaged into syringes for distribution. Production capacity At present, the world has a production capacity of about 300 million trivalent influ- enza vaccines per year, most of which is produced in nine countries – Australia, Canada, France, Germany, Italy, Japan, the Netherlands, the United Kingdom, and the United States. Types of Influenza Vaccine The different types of vaccines in use today for influenza can be divided into killed virus vaccines and live virus vaccines. Other vaccines of these two types are under development, as well as some that do not fall into either category, where a degree of genetic manipulation is involved. Killed vaccines Killed virus vaccines can be divided into whole virus vaccines, and split or subunit vaccines. The influenza virus was grown in the allantoic sac of embryonated hens’ eggs, subsequently purified and concen- trated using red blood cells, and finally, inactivated using formaldehyde or β- propiolactone. Later, this method of purification and concentration was replaced with centrifuge purification, and then by density gradient centrifugation, where vi- rus particles of a specific density precipitate at a certain level in a solution of in- creasing density. Subsequently, filter-membrane purification was added to the methods available for purification/concentration (Hilleman 2002, Potter 2004). Split and subunit vaccines cause fewer local reactions than whole virus vaccines, and a single dose produces adequate antibody levels in a population exposed to similar viruses (Couch 1997, Hilleman 2002, Potter 2004). However, this might not be sufficient if a novel pandemic influenza virus emerges, and it is believed that two doses will be required. Inactivated influenza virus vaccines are generally administered intramuscu- larly, although intradermal (Belshe 2004, Cooper 2004, Kenney 2004) and intranasal (mucosal) routes (Langley 2005) are being investigated. The master viruses used are A/Ann Arbor/6/60 (H2N2) and B/Ann Arbor/1/66 (Hoffman 2005, Palese 1997, Potter 2004). The vaccine master virus is cold-adapted – in other words, it has been adapted to grow ideally at 25 degrees Celsius, which means that at normal human body temperature, it is at- tenuated. The advantages of a live virus vaccine applied to the nasal mucosa are the devel- opment of local neutralising immunity, the development of a cell-mediated immune response, and a cross-reactive and longer lasting immune response (Couch 1997). Damage to mucosal surfaces, while far less than with wild-type virulent influenza viruses, may lead to susceptibility to secondary infections. Of greater concern for the future is the possibility of genetic reversion – where the mutations causing attenuation change back to their wild-type state – and reassortment with wild-type influenza viruses, resulting in a new strain. However, setting up such a facility takes time and is costly, and most vaccine producers are only now beginning this process. Vaccine Development 131 Reverse genetics allows for specific manipulation of the influenza genome, ex- changing genome segments for those desired (Palase 1997, Palese 2002b). Based on this method, several plasmid-based methods (Neumann 2005) for constructing new viruses for vaccines have been developed, but are not yet in use commercially. These are then detected by the immune system, resulting in both a humoral and cellular immune response (Hilleman 2002). Such vaccines have been shown to be effective in laboratory animals, but data are not available for human studies.

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