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The 1999 survey reflected a change in sampling methodology adopted to minimize bias buy zocor 20 mg overnight delivery cholesterol tester, and the lower prevalences reported in this survey are probably a more accurate representation of actual levels in the country 10mg zocor with amex cholesterol norms chart. Uruguay showed a slight increase in all resistance parameters purchase 10 mg zocor overnight delivery cholesterol ranges hdl; however discount zocor 10mg free shipping cholesterol test gp, the magnitude of overall resistance in the country is, to date, the lowest reported in the region. The sample from Honduras indicated that prevalence of drug resistance is similar to that in the majority of countries surveyed in the region. Chile, which saw only slight and non-significant increases in resistance between 1997 and 2001, has employed one of the most innovative surveillance policies in the region, which may prove to be a useful model for other countries. Chile performs continuous surveillance of all previously treated patients, and conducts a survey on a representative sample of new cases every three years, thus obtaining accurate information on both populations, strengthening routine patient history interviews, and identifying resistance patterns of previously treated patients early in treatment. Brazil, Colombia, Costa Rica, Dominican Republic, Mexico, Panama, and Peru will commence surveys shortly. A second survey in Mexico will be nationwide and not partial as in the 1997 survey. Trends are available only for the Gulf States of Oman and Qatar, both with small numbers of total cases and low to moderate levels of resistance, much of which is imported. Surveys are under way in Jordan, Lebanon, and the Syrian Arab Republic, and the Islamic Republic of Iran and Morocco are preparing for repeat surveys, with nationwide coverage in Morocco. The European region displays the greatest heterogeneity of resistance parameters in the world, including both the highest and the lowest prevalences. Before 2001, drug resistance data in Germany were based on a nationally representative sample covering 55% of local health departments that had elected to report drug susceptibility test results, contributing 50. Since 2001, results of drug susceptibility testing are notifiable by law and are analysed centrally; the higher proportions observed in 2001 and 2002, therefore, do not necessarily reflect an increase over time, but may be due to the methodological change. In France, most resistance parameters among new cases are stable, and resistance in the country is relatively low. Resistance to any drug is increasing significantly in Barcelona, but individual parameters are difficult to interpret. When data were stratified by origin of birth, resistance was higher in the foreign-born population. This, coupled with an increase in immigration in Barcelona since 2000, suggests that the rising prevalence of resistance may be linked to immigration. Israel is an outlier, presenting the highest levels of resistance for most parameters. The situation of this country is unique, because of the high levels of immigration from areas of the former Soviet Union. Data from countries in Central Europe show relatively low prevalences of drug resistance, with indications of an increase in resistance in a few countries. Slovakia has shown steady but non-significant increases in resistance parameters since reporting began in 1998. The first phase of the Global Project identified drug resistance as a major public health problem in areas of the former Soviet Union. The second report reiterated these findings, and evidence from the third phase indicates that drug resistance is of serious magnitude and extremely widespread, and that there are high proportions of isolates resistant to three or four drugs. This increase, coupled with decreasing overall notifications of new cases, results in a prevalence similar to that observed in 1999, around 17%. In Latvia, new case notifications have increased steadily since 1996 as have total number of cases with any drug resistance; this is reflected in a slight but steady increase in prevalence of any resistance since 1998. In order to determine drug resistance trends with any certainty, surveillance of drug resistance must continue. The sample size was based on new cases; however, during the survey intake period approximately equal numbers of new and previously treated cases presented at diagnostic units, and 47% of the total sample was composed of previously treated cases. Very high prevalences of drug resistance have now been confirmed in Estonia, Latvia, Lithuania, Tomsk and Ivanovo Oblasts in the Russian Federation, Kazakhstan and the Aral Sea regions of Dahoguz Velayat, Turkmenistan, and Karakalpakstan, Uzbekistan. Preliminary evidence suggests even higher prevalences in other areas of the former Soviet Union. Currently, surveys are being planned in Kyrgyzstan, Moldova, Georgia, Donetsk (Ukraine), Armenia and Azerbaijan as well as a nationwide survey in Uzbekistan. In order to obtain reliable data from these areas, proficiency testing of national or regional reference laboratories must be carried out immediately. Recently, district surveys were carried out in India, in the states of Maharashtra, Tamil Nadu, and Karnataka. Only well designed state level surveys, sampling new and previously treated cases separately, will be able to assist in ascertaining a baseline prevalence in these populations at the state level. India is developing a plan to conduct nationwide surveillance of drug resistance by state, starting with two states this year and gradually adding and re-surveying states over time, as has been done in China and is planned in Brazil. Prevalences of resistance among new cases from the first and third surveys were similar; however, the second survey found considerably higher prevalence of resistance among new cases. Resistance among previously treated cases (surveyed only in the last two surveys) decreased. Bangladesh constitutes another important gap in drug resistance information in the region and nationwide surveillance there should be a priority. The human and financial capacity of the national reference laboratory needs to be enhanced before proficiency testing can take place and a nationwide survey implemented. China has a progressive surveillance policy and has surveyed six of 31 provinces in the country, with a repeat survey completed in Henan, and repeat surveys planned in Guangdong, Zhejiang, and Shandong provinces. New surveys are under way in Inner Mongolia and Hunan, surveys of Beijing and Shanghai cities are due to start shortly, and surveys are planned in Xinjiang, Heilongjiang, and Chongqing. In both settings, misclassification was difficult to avoid because of previous policies, and this underlines the importance of rechecking records and reinterviewing patients during the course of a survey. Proficiency testing of provincial laboratories that have conducted or are preparing to conduct surveys takes place annually, even after the survey has been completed. Japan provided data from a 1997 nationwide sentinel survey and Mongolia from a 1999 nationwide survey, both showing relatively low prevalences of drug resistance. Resistance in Australia, New Zealand, and the South Pacific islands appears to be largely of foreign origin and low in magnitude at this time. This finding highlights the importance of giving greater attention to this group of patients in terms of treatment, reporting, and representative drug resistance surveillance. In general, the ecological analysis was inconclusive with the exception of the above finding. Despite the inherent weakness in ecological analysis of aggregate data, the conceptual model can constitute a step forward for more reliable and individual data collection. Ultimately the magnitude of the problem rests on the ability of a country to treat patients effectively. Failure to do so will result in a situation where a substandard level of care and irrational use of second-line drugs will continue to perpetuate the transmission of, and potentially amplify further, highly drug-resistant isolates of tuberculosis. The network has completed nine rounds of proficiency testing since 1994; cumulative results over the nine rounds generally indicate overall high performance of the network. Following an evaluation by the supranational laboratory, a decision is made on whether to carry out the survey or repeat proficiency testing. The network has recently agreed such criteria and details will be published in the coming year. Preliminary research has shown that at least one of the apparently borderline isolates was in fact a mixed culture containing one drug-resistant and one susceptible isolate; however, further exploration is warranted. There is a need for these costs to be met internationally to stabilize and enhance the network. The Laboratory Strengthening Subgroup seeks to assess and develop plans for improvement of entire national laboratory networks, with an emphasis on sputum smear microscopy. Improved laboratory networks will translate into improved diagnostic and treatment capacity, and more accurate surveillance of drug resistance. This is not always true of the data from individual sites, where the number of cultures examined is less than 1000, given that some drug resistance types show prevalences of 0. The total number of isolates examined is sufficiently high to guarantee statistical significance of both new cases and previously treated cases, even though all settings within some regions such as the Eastern Mediterranean and South-East Asia are not necessarily representative of the regions as a whole.

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Cauda Equina Defnition: It is a clinical condition arising from dysfunction of multiple lumbar and sacral nerve roots compression within lumbar spinal canal order 10 mg zocor with mastercard cholesterol chart uk. Causes - Massive herniated lumber disc - Tumors - Free fat graf following discectomy - Trauma - Spinal epidural hematoma - Infection e buy generic zocor 20 mg line cholesterol test malaysia. Cerebral Vascular Diseases (Spontaneous Haemorrhage) Intracranial hemorrhage may be subdural cheap 40mg zocor cholesterol lowering vegetarian diet, subarachnoid and intracerebral (intra parancyma) zocor 10mg free shipping cholesterol chart 2015. Subdural hemorrhage is discussed under traumatic causes of intracranial hemorrhages. Intracerebral Hemorrhage Defnition:It is a hemorrhage within the brain parenchyma, commonly referred to as hypertensive hemorrhage, it is the second most common form of strokes (15-30%) but most deadly. Occurs at common sites for hypertensive bleeds (putaminal, thalamic, cerebellar and lobar). Subarachnoid Hemorrhage Description: It occurs as a result of bleeding from aneurismal rapture in 5% from perimesencephalic. Brain Abscess Defnition: Is a pus containing cavity in brain, it goes through stages. Phenytoin 15-20mg /kg as a loading dose and maintenance dose of 5mg/kg/day for 21 days or as long as seizures are present) - Surgery; excision of the cyst Indications for surgery - Large cysts causing mass efect - Cysts causing abstractive hydrocephalus Surgery Clinical Treatment Guidelines 97 Chapiter 2: Neurosurgery 2. Hydrocephalus in Children Description: It is a condition that results when normal exit and absorption of cerebral spinal fuid in the ventricles are impaired. Tis leads to progressive accumulation of this fuid in the ventricles of the brain, resulting in progressive damage to the developing brain with associated mental retardation and visual impairment. Causes - Congenital abnormality - Intraventricular hemorrhage - Infection - Head trauma - Brain tumor Signs and symptoms - Accelerated head growth - Te baby’s sof spot (anterior fontanelle) is usually full or bulging, or even tense, due to the increased pressure inside the head. Myelomeningocele Defnition: Congenital defect in vertebral arches with cystic dilatation of meninges and structural or functional abnormality of spinal cord or cauda equina. It is broadly classifed into 2 entities: - Open head trauma in which there is a scalp laceration with underlying skull fracture and breached Dura Mater (i. It can also be classifed by severity into mild, moderate and sever head trauma depending on the level of consciousness. Patients with severe maxillofacial injury will also need to be given a tracheostomy. Mannitol should be used with caution in patients with clotting disorders because it afects coagulation, and in congestive heart failure patients it increases intravascular volume before it causes diuresis. Remember steroids (dexamethasone, hydrocortisone) have no place in management of acute head injury. Complications - Post-traumatic seizures - Permanent neurological disability - Post-traumatic hydrocephalus - Post-Concussion Syndrome - Infection e. It is subdivided into acute (< 72hours) Subacute (between 72 hours and 3 weeks) and Chronic ( > 3weeks). Chronic Subdural Hematoma Cause - Minor head injury or fall ofen not remembered by patients or relatives. Epidural Hematoma Defnition: It is the collection of blood between the skull and the Dura Mater caused by a rupture of artery and vein in epidural space, as a result of a fracture of the skull at the moment of the impact in 60-90% of cases. Intracranial Hematoma Defnition: Traumatic intraparancymal hemorrhage is commonly associated with brain contusion. Simple Rib Fracture Defnition: Simple rib fracture is a break in continuity of the rib(s). Flail Chest Defnition: Segmental fracture of rib(s) resulting in paradoxical movement of the chest that may lead to respiratory dysfunction. Pneumothorax Defnition: Collection of air in pleural cavity which can be either simple or under tension resulting in pressure on the mediastinum. Cardiac Tamponade Defnition: Te collection of blood in pericardium causing cardiac dysfunction. Ruptured Diaphragm Defnition: A tear in the diaphragm which allows protrusion of abdominal organs in the chest. Pulmonary Fibrosis and Bronchectasis Defnition: Fibrosis of the lung following bacterial infection and/or lung abscess. Lung Cancer Defnition: Malignant growth of the bronchials or parenchyma of the lung. Mediastinum Masses Defnition: Space occupying lesions that may be solid or cystic located in the mediastinum compartment. Note: For more information refer to relevant textbooks (Short Practice of Surgery by Bailey and Love and Principles of Surgery by Schwartz) 3. Congenital Diaphragmatic Hernias Defnition: Is the herniation of abdominal viscera into the chest cavity through a congenital defect of the diaphragm. Abdominal Injuries Defnition: It is an injury to the abdomen, it may be blunt or penetrating and it may involve damage of abdominal organs. Colon Injury - Immediate surgery - Primary closure and proximal defunctioning colostomy/ ileostomy - Peritoneal lavage - Excision and exteriorization of two ends with re-anastomosis at 3months 4. Rectal Injury - Most ofen penetrating - Can occur with pelvic function Diagnosis - Blood on examination glove - Sigmoidoscopy Management - Primary repair - +/- colostomy - +/- pre-sacral drainage 128 Surgery Clinical Treatment Guidelines 5. Oesophagial Atresia Defnition: Congenital disorder with a blind end to the oesophagus, at frst feed the infant coughs and may become cyanosed. Cause - Congenital Signs and symptoms - Drooling, poor feeding, cyanosis, coughing, gagging, and chocking with attempted feeding tube is not able to pass all the way to stomach. Diagnosis - Clinical Investigations - X-ray with contrasts of oesophagus shows an air flled pouch and air in the stomach and intestines - Inserted feeding tube appear coiled up in the upper oesophagus - Oesophagocopy 5 - Chest x-ray Complications - Aspiration pneumonia - Chocking and possible death - Feeding problems - Refux afer surgery - Stricture of the oesophagus Management - Oesophagial atresia is considered a surgical emergency - Feeding gastrostomy Surgery Clinical Treatment Guidelines 129 Chapiter 5: Disorders of Gastro-Intestinal System - Control of electrolytes imbalance replace accordingly with corrective measures of dehydration - Ensure nutritional support - Good oxygen circulation - Put the patient in the most comfortable position - Education to the patient and the family on the management of the gastrotomy tube to avoid infection 5. Achalasia Defnition: It is a disorder of the oesophagus which afects the ability to move food towards the stomach. Causes - A primary neurological disorder of unknown cause - Failure of the cardiac sphincter to relax - Faulty peristalsis of the oesophagus due to defective parasympathetic innervations - Cancer of the oesophagus in the upper stomach Signs and symptoms - Regurgitation of food - Chest pain increasing afer eating may also be felt in the back, neck and arms - Cough - Heart burn - Unintentional weight loss - Signs of anaemia or malnutrition Investigations - Oesophagium manometry - Esophagogastroduodenoscopy - Upper Gastro-intestinal x-ray with barium meal Complications - Regurgitation - Aspiration pneumonia - Perforation of esophagus 130 Surgery Clinical Treatment Guidelines Chapiter 5: Disorders of Gastro-Intestinal System Management - Management of achalasia aims at reducing pressure at the lower esophageal sphincter • Injection with Botulinum toxin to relax sphincter muscles • Medication such as long acting nitrates or calcium channel blockers to relax lower esophagus sphincter • Surgery: Esophago myotomy to decrease pressure in the lower sphincter • Dilatation of esophagus at the location of narrowing done during Esophagogastroduodenoscopy 5. Gastroesophagial Refux Disease Defnition: It is a condition caused by retrograde passage of gastric contents into the esophagus resulting in infammation (oesophagitis), which manifests as dyspepsia. Esophageal Cancer Defnition: It is a malignant tumour of the oesophagus, which may be squamous cell carcinoma or adenocarcinoma. Esophageal Spasm Defnition: Difuse oesophagal sphasms are uncoordinated contractions of oesophagus resulting from motility disorders. Perforation of oesophagus Defnition: It is a hole through which the contents of oesophagus can pass into the mediasternum, the surrounding area in the chest. Hiatus Hernia Defnition: It is the protrusion of the upper part of the stomach into the thorax through a tear or weakness in the diaphragm. Acute Abdomen Defnition: Acute abdomen is used to describe a group of acute life-threatening intra abdominal conditions (including pelvis) that require emergency hospital admission and ofen emergency surgical intervention. Early recognition, adequate resuscitation and prompt treatment are necessary for recovery of these patients from potentially fatal conditions. Intestinal Obstruction Defnition: It is the inability to pass bowel contents distally (partial or complete). Causes - Extramural - Adhesions, bands - Hernias: internal and external - Compression by Tumors - Intramural - Infammatory disease: Crohn’s disease - Tumors: carcinomas, lymphomas, etc. Surgery is the most important step, and in case of strangulation or vascular occlusion it is the only efective treatment. Surgical procedures for the relief of intestinal obstruction may be divided into fve categories. Causes/Predisposing factors - No clear cause of appendicitis - Obstruction of appendiceal lumen - Infammation of appendiceal lymphoid tissue (about 60%). Tis infammation can be - Gastroenteritis - Advanced colonic disease such as Crohn’s Disease. Appendiceal Mass and Abscess Defnition: Appendiceal mass is a palpable conglomeration of infamed tissue, including the appendix and adjacent viscera.

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Except as expressly provided above trusted zocor 20mg cholesterol foods, no part of this publication may be reproduced or transmitted in any form or by any means order zocor 10 mg visa cholesterol jokes, electronic or mechanical generic zocor 40mg with mastercard cholesterol medication list, including photocopying cheap 20mg zocor otc cholesterol supplements, recording, or by any information storage and retrieval system, without written permission of the author or authors. This material is intended for educational use only by practicing health care workers or students and faculty in a health care field. Part one includes the following five chapters: Principles of physiology, Excitable tissues (nerve and muscle), physiology of blood, Cardiovascular physiology and Respiratory physiology; Part two contains the following seven chapters: physiology of the renal system, physiology of the gastrointestinal system, physiology of the endocrine system, physiology of the reproductive system, Neurophysiology, physiology of the Special senses and the Autonomic nervous system. We express sincere appreciation to the secretaries for meticulous computer type settings of the teaching material. Concentration and permeability of ions responsible for membrane potential in a resting nerve cell. Both structure and function must be studied at all levels from the cellular to the molecular to the intact organism. There is immense genetic diversity, as a result of small spontaneous change in individual genes, called mutation, occurring from time to time. The natural selection concept of Charles Darwin emphasizes the predominance of the genes in the population that favors survival of the fittest and reproduction in a particular environment. Early with life on earth cells developed the ability to react with oxygen and carbon compounds and use the energy released by these chemical reactions. With complexity of development cells evolved structure called mitochondria for efficient energy production. The efficiency of oxidative phosphorylation was maximized in natural selection of the best. Some aspects of human physiology may be rapidly changing on the evolutionary scale of time. The brain capabilities are probably still rapidly evolving as new pressures are faced. For pain with injury, a warning signal results in sudden withdrawal of the injured part, protecting it from further injury. But step-by-step sequence of events starts with the injury and eventually ends with the contraction of group of muscles that flex the injured limb - stimulus, receptor, electric signals, spinal cord, flexor muscles. The circuit that creates this response is genetically determined and is formed during early development of the nervous system. Levels of structural organization: From single cell to organ system cells are the basic units of living organisms. Humans have several levels of structural organizations that are associated with each other. The chemical level includes all chemicals substances essential for sustaining life. The diverse chemicals, in turn, are put together to form the next higher level of organization, the cellular level. The different types of muscle tissue are functional adaptation of the basic contractile system of actin and myosin. Skeletal muscles are responsible for movement of the skeleton, cardiac muscle for the contraction of the heart that causes blood circulation; smooth muscle is responsible for propelling contents within soft hollow organs, such as the stomach, intestine, and blood vessels. Cardiac muscle fibers branch but are separated into individual cell by continuity of the plasma membrane, the intercalated discs. Nervous System- Conducting signals This tissue is specialized for conduction and transmission of electrical impulses and the organization of these nerve cells or neurons is the most complex of any of the tissue. The neuron has a cell body that contains the nucleus and the other organelles with very high metabolic activity (e. The neuron is further specialized for having processes, which contact it through the synapses to other neurons, making a long chain of conducting tissue linking the various parts of the body. It includes the membranes that cover body surfaces and line hollow viscera internal organs, forming barrier between the interior of the body and the environments. Epithelial cells may be modified to function as sensory receptor, detecting specific stimuli from the environment. Epithelial cells also form the endocrine glands (pituitary, parathyroids, thyroid, adrenals, ovary, and testis), which secrete 3 hormones directly into the blood and the exocrine glands secrete substances via ducts (e. Connective Tissue It is mesodermal in origin and functions in supporting, connecting and transporting. It covers wide variety of tissues, but having more intercellular materials or matrix, than cells. It also contains extracellular fibers, which may be tough collagenous fibers or the resilient elastic fibers. Life processes: The following are the important life processes of humans: Metabolism: includes catabolism and anabolism that provides energy and body’s structural and functional components Excitability: Ability to sense changes in and around us. Conductivity: ability to carry the effects of stimulus from part of a cell to another. The human body contains organic compounds such as lipids, proteins, carbohydrates and nucleic acids. The lipids are important forms of storage fuel in addition to providing insulation of the body as a whole or essential component in the structure of plasma membranes, myelin and other membranes. Proteins serve as the structural basis for all enzymes, contractile muscle proteins, connective tissue, such as collagen and elastin and in addition as a fuel (about 15%), or precursor for carbohydrate in the process of gluconeogenesis. Ingested glucose is converted to glycogen and stored in the liver, muscle and adipose tissue. Components of Body System System Components Circulation Heart, blood vessels, blood Digestive system Mouth, pharynx, esophagus, stomach, small & large ` intestine, salivary glands, pancreas liver, and gallbladder Respiratory system Nose, pharynx, larynx, trachea, bronchi, lungs Urinary system Kidneys, ureters, urinary bladder, urethra Skeletal system Bones, cartilage, joints Muscle system Skeletal muscle Integumentary system Skin, hair, nails Immune system Leukocytes, thymus, bone marrow, tonsils, adenoids, `` lymph nodes, spleen, appendix, gut-associated lymphoid ` tissue, skin-associated lymphoid tissue muscosa ` associated lymphoid tissue Nervous system Brain, spinal cord, peripheral nervous system. Large part of physiology is concerned with regulation mechanisms that act to maintain the constancy of the internal environment. The structure and chemical 6 reactions of living organisms are sensitive to the chemical and physical conditions within and around cells. For multicellular organisms, the surrounding fluid is the interstitial fluid: a component of the extracellular fluid. The intracellular fluid has a high concentration of potassium and low concentration of + - ++ + Na Cl , Mg , and Ca. Body temperature is very crucial for intracellular physiological processes; enzymatic events need a very narrow range of temperature, within the physiological range of temperature compatible with life, cooler temperature favors preservations of cellular structure but slows the rate of chemical reactions carried out by cells. The higher temperature enhances chemical reactions, but may also disrupt the structure of the proteins and other macromolecules within cells. The production of energy for cellular activities requires oxygen and nutrients reaching the cell interior and carbon dioxide and other chemical wastes products be transferred to the environment. Extensive exchange between cells and immediate surroundings, interstitial fluid, occurs by diffusion based on a concentration gradient. Diffusion causes adequate movement of dissolved nutrients, gases and metabolic end products to meet the active needs of the cell, if the distance is short. For the efficiency of diffusion, the diameter of individual cells is usually not more than a few tenths of a millimeter. In the circulatory system, blood rapidly moves between the respiratory system, where gases are exchanged; the kidney where wastes and excess of fluid and solutes are excreted; and the digestive system where nutrients are absorbed. These substances are rapidly transported by blood flow overcoming the diffusion limit on large body size. By maintaining a relatively constant internal environment, multicellular organisms are able to live freely in changing external environment. Responses tend to oppose the change and restore the variable to its set point value. All organ systems have regulatory processes for maintaining a delicate balance in a dynamic steady state.

J. Diego. Hamilton University.

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