There is little doubt: out of two equally competent and detailed medical textbooks 200mcg cytotec with amex medicine park cabins, the one available free of charge on the internet will be the one to win favour with the readers buy cytotec 200 mcg overnight delivery medicine 10 day 2 times a day chart. In a direct confrontation between “book only” and “book + internet”, “books only” have a remote chance of survival. This fact means that the book with the free internet version ultimately gains market shares. The surprising twist is that the free internet version promotes the sale of the fee-based book version. The financial result of a well-planned parallel publication (book + free internet counterpart) can thus be very satisfying in the middle-term. Flying Publisher Pioneer projects The number of readers is one of the most important variables which define the success of a text. We are investigating the extent to which this number is influenced by the publication of a free internet version in three pioneer projects, and can already anticipate the result. The book was then translated into Chinese, French, Italian, Portuguese, Romanian, Spanish and Vietnamese (see http://sarsreference. It was translated into 8 languages because it was free of charge and the copyright had been removed. The decision has been made: we are going to write a medical textbook and publish it both as a book and on the internet. In the last few years, doctors have seen how amazingly self-sufficient they have become in spreading medical 15 1. Think back: how many doctors were familiar with the layout of letters on a typewriter 20 years ago? Back then, we had secretaries, and anyone who was able to touch-type kept this to himself and didn’t give it away to his assistant until after he retired. Better still: we are not only adept at word processing but have also become practised layout designers. Anyone who has published scientific articles in medical journals has learned that he must “format” his texts in accordance with strict regulations. After all, the work performed in the medical publishing houses must be reduced to a minimum. Which brings us to the conclusion: if proofreading is the only thing that stays in the hands of the publishers, why don’t we just take over the whole production process? The only problem left would be distribution, which – as we will see later on – is a problem which can be solved for medical textbooks, 90% of which are sold in a relatively small number of specialised bookstores. So, let us put the question more precisely: what do we do if we have a finished manuscript? Do we go to a traditional publishing house or is it more beneficial to produce the book in our own garage? There is sometimes a sense of shame at the idea of publishing a written text ourselves. The argument: publishing houses are seen as a supervisory body, and it is this supervision that awards our texts the seal of approval, sanctifies our work, and renders sacred our Opus urbi et orbi. In the medical publishing houses, more and more doctors are being replaced with economists. This may make sense within the business, but are economists the right people for us to talk to? Secondly, some medical publishing houses have suffered from globalisation, philosophy of efficiency and lean production structures. In the past, bestsellers existed to bring in enough money to help finance books which were not highly profitable but represented a meaningful supplement to the range. The tendency today, not surprisingly, is to avoid having to keep any exotic types on the payroll if at all possible, and to play safe and secure the financing of a new title right from the start by selling part of an edition to a pharmaceutical company. Thirdly, and this is perhaps the saddest point for doctors: morals are becoming rougher, the rules of courtesy are sinking into oblivion. Flying Publisher generation ago, old people say, courtesy and reserve ruled over any contact between doctors and publishers. In the age of rapid production, the doctor is becoming a supplier of raw material, has to meet delivery deadlines more than ever and is treated the way many people tend to treat delivery men: rudely. But to come back to the point mentioned at the beginning, that publishers are an important supervisory factor for the quality of our texts. In principle, supervisory bodies make sense, but are publishers the right ones for the job? Who has the right to decide whether something written by someone who has been practising his profession for 20 or 30 years should be published? The short-term image boost is stronger if your book is published by an established publishing house. The arguments that go against an author having a contract with a traditional publisher are: as a rule, you have to cede the rights to your own text; it is seldom possible today to persuade publishers to present a free parallel publication of the text on the internet; producing your own book can be considerably more lucrative. Thus, the following speak in favour of publishing your medical textbook by yourself: 1. The better establishment of your textbook in the long-term, since the parallel publication of a text both as a book and an internet version is still rare today. This gives you a selective advantage over authors who continue to publish their texts as books only. We therefore advise all colleagues to produce and market their textbooks themselves. Print: the share that print costs have in the retail price depends on the size of circulation and the price. Distribution: the share of distribution costs amounts to approximately 45% of the retail price. This percentage is irrespective of the distribution channels (book wholesaler, sponsors). Profit: depending on circulation, profit is somewhere between 27 (100% - 45% - 28%) and more than 40% (100% - 45% - 13. The future reader (R) goes into a bookshop (B) and pays the retail price (yellow arrow). The bookseller or wholesaler pays the publishing house (X) after deducting a sales margin of 30 to 45%. The publisher has previously transferred payment for the printing costs to the print shop (P) and pays the authors off over several months or years. The publishers are out of the game and the authors market the books directly through the most important specialised medical bookshops. The future reader (R) goes into the bookstore (B), pays the retail price, and the bookseller remits 70% of this to the authors (A). The authors have previously transferred payment of the printing costs to the print shop (P). In this diagram, we have replaced the bookstore with a sponsor, such as a foundation (S). The sponsor pays the authors for the discounted books, and the authors in turn pay the printer (P).
On microscopy discount cytotec 200mcg amex treatment centers in mn, large amounts of epithelioid and giant multinucleated cells can be observed in the granulomas buy generic cytotec on-line symptoms kidney failure, located mainly around the caseous mate- rial. The nature of the host immune response will determine whether the infection will progress or be contained. In the human infection, however, such a clear division into two different cytokine response patterns is not observed. In view of this, the disease can occur: • during the initial phase of infection - due to excessive bacillary load, in- creased bacterial pathogenicity/virulence and/or factors that decrease host immune response. It commonly occurs during childhood (see Chapter 16), and may occasionally cause malaise, low-grade fever, erythema nodosum, and phlyctenular conjunctivitis. Tuberculosis infection 491 pressure, and are usually located bilaterally on the anterior surface of feet and legs. The classical pres- entation is known as the primary Ranke’s complex, including a calcified peripheral lung nodule (Gohn’s primary focus), lymph tracts toward the hilus (lymphangitis), and enlarged local lymph nodes (Figures 15-3 and 15-4). Figure 15-3: Chest X-ray showing a calcified peripheral nodule in the lower right lung (Gohn’s primary focus) (Reproduced from Melo 2005a) a b Figure 15-4: a: Chest X-ray showing a calcified peripheral nodule in the lower right lung, lym- phangitis (encircled in b) and hilar involvement (Ranke’s complex) (Reproduced from Melo 2005a). Tuberculosis disease 493 ceptor deficiency, it can develop into a disseminated form, which is sometimes fatal. High morbidity in the primary form was also observed in patients whose ancestors were not previously exposed to the tubercle bacillus, as reported in the Yanomami Indians in the Amazon Region (Sant´Anna 1988, Souza 1997). Recently, in African countries, using molecu- lar typing methods, it has been shown that the transmission is community driven, and not solely through households, and that reinfection with novel M. Lymphatic dis- semination can occur, but in this case the hilar lymph nodes are usually not af- fected. The response to bacillary multiplication provokes caseous necrosis that eventually blends and progresses to liquefaction. Tubercle bacilli, whose multipli- cation had been until then inhibited by granuloma formation, find favorable condi- tions for population growth after liquefaction of the caseum and subsequent cavita- 8 tion, and may produce more than 10 bacilli per cavity with a diameter of less than 2 cm. The natural evo- lution of post-primary lesions in immunocompetent persons can lead to dissemina- tion and death in about 50 % of cases, and to chronicity in about 25 % to 30 %. Natural cure can also occur in 20 % to 25 % of cases, when the host immune re- sponse is able to re-establish control of the disease (Bates 1980, Melo 1993). In most non-immunosuppressed persons infected by the tubercle bacillus, disease will occur in the first three to five years after the initial exposure. The remaining cases occur at any time during a 494 Tuberculosis in Adults lifetime, especially when there are other diseases or weakening conditions, for example malnutrition, diabetes, prolonged treatment with corticosteroids, immuno- suppressive therapy, chronic renal disease, gastrectomy, and others. The post- primary disease presents a great spectrum of manifestations, which are related to the affected organ. The lungs are most commonly affected, usually in the upper lobes or apical segments of inferior lobes. The disease can also affect other organs, including lymph nodes, pleura, kidneys, the central nervous system, and bones. With respect to respi- ratory signs and symptoms, the patient may complain of cough of insidious evolu- tion, at any hour of the day, which as initially dry and later on productive with purulent or mucous expectoration. Hemoptysis and bloody sputum occur in less than a quarter of patients, with the worst cases originating from lesions invading blood vessels. Few crackles can be noticed on auscultation after deep inspiration and also ronchi and tubular sounds. Such delays in diagnosis may be due to low diagnostic suspicion by the medical personnel, lack of access to health services, because the patient may not acknowledge being sick or may not seek medical help due to eco- nomic or cultural reasons. An early diagnosis is critical for controlling transmission of the disease in the community, especially in congregated institutions, such as hospitals, prisons, and shelters. It is crucial to perform the diagnosis in the initial phase of this type of presentation in patients with recent symptoms (less than four weeks) (Figure15-6). If diagnosis is delayed, the disease may evolve rapidly, destroying the pulmonary parenchyma (Figures 15-7 and 15-8). In the past, it was recognized as a sign of the tubercle bacilli seeking a route for air- borne dissemination (Figure 15-7). Tuberculosis disease 495 a b c Figure 15-6: Parenchymal infiltrate in the upper left lung, in posteroanterior (a and b) and lordotic position (c). After achieving cure, respiratory symptoms such as a productive cough persist in some patients for several years. When the patient refers to recurrent hemoptysis with elimination of more than 15-50 mL of sputum per day, bronchiectasis and/or a fungus ball may be present (Figure 15-10). Figure 15-10: Chest X-ray showing fibrotic infiltrate and cavity with a fungus ball in the upper left lobe. After this, tubercle bacilli can multiply at any time when there is a decrease in the host’s immune capacity to contain the bacilli in their implantation sites. The specific signs and symptoms will depend on the affected organ or system, and are characterized by inflammatory or obstructive phenomena. For this reason, the extrapulmonary disease gener- ally has an insidious presentation, a slow evolution and paucibacillary lesions and/or fluids. Access to the lesions through secretions and body fluids is not always possible, and for this reason, invasive techniques may be necessary in many cases, to obtain material for diagnostic investigation. Tissues and/or body fluids should be submitted to laboratory examination, in particular bacteriological culture for myco- bacteria and histopathological analysis. Nevertheless, the chest X-ray is mandatory for the evaluation of evidence of primary infection lesions, which provide a good verification to support the diag- nosis (Rottenberg 1996). Its onset may be either insidious or abrupt, depending on the bacillary load and/or the host immune situation, with unvacci- nated infants, elderly and immunodeficient patients being the most susceptible (Lester 1980, Thornton 1995). Other specific symptoms depend on the organs affected, and involvement of the central nervous system occurs in 30 % of cases. The physical examination is unspecific, and the patient can present 498 Tuberculosis in Adults with variable degrees of wasting, fever, tachycardia and toxemia. Chest X-ray shows a characteristic diffuse, bilateral and symmetrical micronodular infiltrate (Figure 15-8). The onset of the disease may be insidious or abrupt, with fever, systemic complaints, dyspnea, dry coughs, and pleuritic thoracic pain. The pleural effusion is generally unilateral and moderate, and can easily be de- tected by conventional chest X-ray examination (Figure 15-12). The differential diagnosis for pleural effusions includes para-pneumonic pleural effusions, mycoses, malignant diseases, and, especially in young women, collagen vascular diseases. Most of the time, the effusion is resolved, even if not treated, leaving minimal or no radiological sequelae. The preferential localization is the anterior cervical lymph node chain with little predominance of the right side chain. Patients mainly complain of fever and the increasing vol- ume of lymph nodes, but other symptoms may be absent.
Although there is a considerable regional variation in their relative thickness: the epidermis is thickest on the palms and soles and very thin on the eyelids 200 mcg cytotec otc ombrello glass treatment. Cells of the epidermis Keratinocyte - produces keratin which forms the outer most skin layer covered by thin lipids to give the skin protective capacity from water and heat loss generic cytotec 100 mcg medications held before dialysis, penetration of microbial agents, and other trauma by physical mechanisms. The number of melanocytes in the epidermis is the same, regardless of the person’s race or skin color; it is the number , shape and size of melanosomes (melanin containing granules) and the type of melanin that determine difference in skin color. They are found in the epidermis but they constantly move as a result, they transport antigens to the regional lymph nodes and present them to naïve T lymphocytes in the regional lymph nodes and consequently the naive T lymphocytes become recruited to the specific antigen and the resultant immunologic response occurs. In this way, the skin is very crucial part of the immune system because of the large surface area that it spans. Protection: it protects the body from many environmentally unfavorable factors; such as, thermal, chemical, ultra violet radiation and different disease-causing microorganisms. Immunologic: the skin is an end organ for many immunologically mediated disorders as well as a tool for immunologic research. The skin can be viewed as a peripheral arm of the immune system involved in normal homeostasis and host defense. Synthetic function: the skin synthesizes vitamin D, different hormones, melanin, and other substances. While describing skin lesions, the following features should be identified: Sites involved and distribution: - if lesions are affecting both sides of the body symmetrically, it probably could have an endogenous origin (e. Primary lesions Macule: flat lesion due to a localized color change only; the surface is normal (size <1cm) Patch: similar to a macule but the size (> 1cm) Nodule: any elevated lesion (> 1cm diameter) which has a round surface (i. Fissure: linear split in the epidermis or dermis at an orifice (angle of the mouth or anus), over a joint or along a skin crease. Surface features Normal/ smooth: the surface is not different from the surrounding skin and feels smooth Scaly: dry/flaky surface due to abnormal stratum corneum with accumulation of or increased shedding of keratinocytes. Friable: surface bleeds easily after minor trauma Crust: dried serum, pus or blood Excoriation: localized damage to the skin due to scratching. Lichenification: thickening of the epidermis with increased skin markings due to persistent scratching. Umblicated; surface contains a round depression in the centre, characteristics of molluscum contagiosum or herpes simplex. Purpose of the Module The ultimate purpose of this training module is to produce competent Health Officers who can correctly identify and effectively manage common dermatologic problems both in clinical and community settings. Direction for Using the Satellite Module This satellite module can be used in the basic training of Health Center team particularly health officers who are in the training and service programs. In order to make maximum use of the satellite module, the health officer should follow the following directions. Use listed references and suggested reading materials to supplement your understanding of the problem. For total and comprehensive understanding of the causes (etiology/pathogenesis) and prevention of common skin diseases, the Health Officer Students are advised to refer to the core module. Discuss the functions of skin in terms of a) Protection b) Thermoregulation c) Immunologic function d) Synthesis e) Others 2. A two year old child presented with itchy, faintly papular eczematous lesions on both cheeks, forehead and neck. Skin colored papules and nodules with shining surfaces and umblicated top were noted on a four year old child. A six year old child presented with high fever, pain, and diffusely swollen left leg of two day duration. On examination of the limb; erythematous, grossly swollen, hot, and tenderness elicited with left side inguinal lymphadenopathy which was also tender. Bacterial infection of the skin (pyodermas) Bacterial skin infection is one of the commonly encountered problems in the tropics. When the normal protective functions of the skin are altered by trauma (scratching and excoriation ), pre existing and/or coexisting skin diseases like, eczema, scabies or venous or lymphatic insufficiency, pathogenic organisms get access to the skin to establish infection. Two main clinical forms are recognized: non-bullous impetigo (or impetigo contagiosa) and bullous impetigo. Impetigo presents as either a primary pyodermal of intact skin or a secondary infection due to preexisting skin disease or traumatized skin. Impetigo rarely progresses to systemic infection, although post streptococcal glomerulonephritis may occur as a rare systemic complication. Bullous impetigo is most common in neonates and infants Causative agents It is caused by Staphylococcus aureus. The non-bullous form is usually caused by group Aβ streptococcus, in some geographical areas Staphylococcus aureus or by both organisms together. Clinical features Non-bullous impetigo: The characteristic lesion is a fragile vesicle or pustule that readily ruptures and becomes a honey-yellow, adherent, crusted papule or plaque and with minimal or no surrounding redness and usually occurs on hands and face. Bullous impetigo: The characteristic lesion is a vesicle that develops into a superficial flaccid bulla on intact skin, with minimal or no surrounding redness. The roof of the bulla ruptures, often leaving a peripheral collarette of scale if removed; it reveals a moist red base. Topical antibiotics can be used, such as 2% mupirocin, Gentamycine, Fucidic acid can be used but costly. Systemic treatment: - for impetigo contagiosa, a single dose of benzathin penicillin coupled with local care. The underlining skin conditions such as eczemas, scabies, fungal infection, or pediculosis should be treated. When impetigo is neglected it becomes ecthyma, a superficial infection which involves the upper dermis which may heal forming a scar. A furuncle is an acute, deep-seated, red, hot, tender nodule or abscess that evolves around the hair follicle and is caused by staphylococcus aureus. A carbuncle is a deeper infection comprised of interconnecting abscesses usually arising in several adjacent hair follicles. Cellulitis and Erysipelas Cellulitis is bacterial infection and inflammation of loose connective tissue (dermis subcutaneous tissue) Erysipelas is a bacterial infection of the dermis and upper subcutaneous tissue; characterized by a well-defined, raised edge reflecting the more superficial (dermal) involvement Etiology The most common etiologic agent is group A β hemolytic streptococcus. In young children, Hemophilus influenza type B should be considered as a possible etiology for cellulites especially of the face (facial cellulitis). Classical erysipelas starts abruptly and systemic symptoms may be acute and severe, but the response to treatment is more rapid. In erysipelas, blisters are common and severe cellulitis may also show bullae or necrosis of epidermis and can rarely progress to fasciitis or myositis. A skin break, usually a wound even if superficial, an ulcer, or an inflammatory lesion including interdigital fungal or bacterial infection, may be identified as a portal of entry. Complications Without effective treatment, complications are common - fasciitis, myositis, subcutaneous abscesses, and septicemia. Crystalline penicillin or procaine penicillin is the first line therapy and oral Ampicillin or Amoxicillin may be used for mild infection and after the acute phase resolves. It is caused by over growth of Corynebacterium minutissimum, which usually is present as a normal flora of the skin. It occurs most commonly in the groins, axillae and the intergluteal and submammary flexures, or between the toes. The duration of therapy varies, but 2 weeks is usually sufficient for topical fucidin and erythromycin.
Operative treatment • Special circumstances may merit open reduction and fxation → Selected segmental fractures → Inadequate closed reduction → Floating elbow → Bilateral humeral fractures → Open fractures → Multiple trauma → Pathologic fractures → Humerus fracture with associated vascular injuries requiring exploration may beneft from internal fxation - Tere are two general forms of internal fxation namely • Compression plate and screw fxation • Intramedullary nailing: especially useful in osteopenic bone cytotec 200mcg cheap medications bladder infections, segmental and external fxator if contaminated open fractures Note: Be aware of radial nerve injury Surgery Clinical Treatment Guidelines 9 Chapiter 1: Orthopaedic Surgery 1 discount cytotec online visa symptoms graves disease. Fractures of Proximal Humerus Classifcation (Duparc and Neer) Fractures are classifed by the number of parts that are displaced more than 1 cm or angulated more than 45 degrees. Pelvic Ring Disruption Classifcation (Tile) Clinical and radiological evaluation of the pelvis based on identifcation of the grade of stability or instability, this is the platform for further decision-making. Fractures of the Acetabulum Classifcation (Letournel) - Type A: Partial articular fractures, one column involved • A1: posterior wall fracture • A2: posterior column fracture • A3: anterior wall or anterior column fracture - Type B : Partial articular fractures (transverse or T type fracture, both columns involved) • B1: transverse fracture • B2: T-shaped fracture • B3: anterior column plus posterior hemitransverse fracture - Type C: Complete articular fracture (both column fracture, foating acetabulum) • C1: Both column fracture, high variety • C2: Both column fracture, low variety • C3: Both column fracture involving the sacro-iliac joint 16 Surgery Clinical Treatment Guidelines Chapiter 1: Orthopaedic Surgery 1 Management Te goal of treatment is to attain a spherical congruency between the femoral head and the weight-bearing acetabular dome, and to maintain it until bones are healed. Femoral Neck Fractures Classifcation (Garden) - Type 1: Valgus impaction of the femoral head - Type 2: Complete but non displaced - Type 3: Complete fracture, displaced less than 50% - Type 4: Complete fracture displaced greater than 50% Tis classifcation is of prognostic value for the incidence of avascular necrosis: Te higher the Garden number, the higher the incidence Management Initial treatment • Traction may ofer comfort in some patients but do not improve overall outcome Defnitive treatment • Internal fxation Surgery Clinical Treatment Guidelines 19 Chapiter 1: Orthopaedic Surgery 1. Femoral Shaft Fractures Classifcation (Winquist) - Type 1: Fracture that involves no, or minimal, comminution at the fracture site, and does not afect stability afer intramedullary nailing - Type 2: Fracture with comminution leaving at least 50% of the circumference of the two major fragments intact - Type 3: Fracture with comminution of 50–100% of the circumference of the major fragments. Distal Femur Fractures Tese fractures involve the distal metaphysis and epiphysis of the femur. Management Non displaced fractures • Walking cylinder cast or brace for 6–8 weeks followed by knee rehabilitation. Displaced fractures • Open reduction and immobilization by fgure-of-eight tension banding over two longitudinal parallel K-wires. Surgery Clinical Treatment Guidelines 21 Chapiter 1: Orthopaedic Surgery • If the minor fragment is small (no more than 1 cm in length) or severely comminuted, it may be excised and the quadriceps or patellar tendon (depending upon which pole of the patella is involved) sutured directly to the major fragment. Management Undisplaced or minimally displaced/ too comminuted to be fxed • Conservative treatment by cylinder cast immobilization for 6-8weeks Severe displacement • Operative treatment by tension band wiring • Alternative: excision of the patella and repair of the defect by imbrication of the quadriceps expansion 1. Tibia-Fibula Fractures Te Tibia has a subcutaneous anteromedial border and is bound to be associated with signifcant sof tissue injury. Classifcation (Tscherne and Oestern): classifed as sof tissue injury in ascending order of severity - Grade 0: Sof-tissue damage is absent or negligible. Isolated Fibula Diaphysis Fractures: Te isolated fbular fracture usually heals independently of the form of treatment. At 6 weeks, some shaf fractures are stable enough to be put in a short leg weight-bearing cast (Sarmiento). At 6 weeks, some shaf fractures are stable enough to be put in a short leg weight-bearing cast (Sarmiento). Fractures of the Distal end of the Tibia Also referred to as pilon or plafond fractures, these fractures involve the distal articular surface of the tibia, the tibiotalar joint and usually the shaf of the fbula. Once sof-tissue swelling subsides, minimally invasive open reduction and percutaneous techniques should be attempted. Ankle Fractures Classifcation (Weber) - Type A • Avulsion of the fbula to the joint line • Syndesmotic ligament intact • Medial malleolus undamaged or fractured in a shear –type pattern with the fracture line angulating in a proximal- medial direction from the corner of the morti: • Oblique orOblique or spiral frala beginningfbula beginning at the level of the joint up to the shaf of the fbula. Surgery Clinical Treatment Guidelines 25 Chapiter 1: Orthopaedic Surgery • Medial malleolus intact or sustain a transverse avulsion fracture. If the medial malleolus is lef intact there can be a tear of the deltoid ligament. Management Principles of initial treatment of ankle fractures • Immediate closed reduction and splinting, with the joint held in the most normal position possible to prevent neurovascular compromise of the foot. If this fragment represents less than 25% of the articular surface of the tibial plafond and there is less that 2 mm of displacement, internal fxation is not always required. In the rare instance of symptomatic non-union, careful excision is indicated • Intra-articular fractures → Treatment of displaced intraarticular fractures remains controversial → Some surgeons still advise conservative treatment → Other surgeons advocate early closed manipulation of displaced intra-articular fractures, to at least partially restore the external anatomic confguration of the heel region. Internal fxation with percutaneous pins (Essex-Lopresti technique) may be performed. Fractures and dislocations may disrupt this vascularization, causing delayed healing or avascular necrosis. Management Type 1 • Non-weight–bearing below-knee cast for 2–3 months until clinical and radiologic signs of healing are present Type 2 • Closed reduction. If open reduction, with or without bone grafing, is elected, prolonged protection from weight bearing is the best means of preventing collapse of the healing area. Fractures of the Phalanges of the Toes Management - A weight-bearing removable immobilization - Spiral or oblique fracture of the proximal or middle phalanges of the lesser toes can be treated adequately by binding the involved toe to the adjacent uninjured toe (buddy taping) - Comminuted fractures of the distal phalanx are treated as sof- tissue injuries 1. Fracture of the Sesamoids of the Great Toe Management - Undisplaced fractures: Hard-soled shoe or metatarsal bar - Displaced fractures: Immobilization in a walking boot or cast, with the toe strapped in fexion - If conservative modalities have been exhausted: Te last resort treatment is excision - Treatment of fractures in children: Te treatment of the majority of fractures in children and adolescents will be conservative. Indications for surgical treatment of fractures in children include: • Open fractures • Polytrauma • Patients with head injuries • Femoral fractures in adolescents • Femoral neck fractures • Certain types of forearm fractures • Certain types of physeal injuries • Fractures associated with burns 32 Surgery Clinical Treatment Guidelines Chapiter 1: Orthopaedic Surgery 1 1. Epiphyseal Fracture Te cartilage physeal plates are a region of low strength relative to the surrounding bone and are susceptible to fracture in children. Tus, open reduction is more likely in fractures involving physes and joints than in other pediatric fractures. Forearm Fracture In children, most forearm fractures that involve both bones can be treated successfully by closed reduction and casting. Minor angular mal-alignment can easily be tolerated if rotational alignment of the bone end is accurate. Rarely severely angulated or rotationally mal-aligned metacarpals and phalanges can be managed by immobilization for 2–3 weeks. Gross displacement is fairly uncommon and can usually be treated symptomatically because the intact periosteum stabilizes the large fat bones. Femoral neck fractures in children are generally treated by reduction and fxation. In rare and unstable cases, some open fractures, or fractures in older children may also require operative treatment. Open Fractures Defnition: An Open Fracture is when disruption of the skin and underlying sof tissue results in communication between the fracture and the outside environment. Causes - Motor vehicle accidents - Farm accidents - Sports accidents - A force large enough to cause a fracture Signs and symptoms - Associated with neuro-vascular injury 36 Surgery Clinical Treatment Guidelines Chapiter 1: Orthopaedic Surgery 1 Diagnosis - Clinical examination of the specifc fracture should include the site of the fracture and severity of the fracture. Te primary injury is the result of the 38 Surgery Clinical Treatment Guidelines Chapiter 1: Orthopaedic Surgery 1 initial, mechanical forces, resulting in shearing and compression of neuronal, glial, and vascular tissue. Te secondary injury is described as the consequence of further physiological insults, such as ischaemia, re-perfusion and hypoxia, to areas ‘at risk’ in the brain in the period afer the initial injury. Critical care of multiple injuries Defnition: Multi-trauma are physical insults or injuries occurring simultaneously on several parts of the body. General Consideration Defnition: Complete separation and loss of 2 articulating bone contact surfaces. Acromio-Clavicular Joint Dislocation Defnition: Classifed in 6 diferent types depending on which ligaments are sprained or torn. Recommendations - Physical therapy under supervision post immobilization removal - Pre and post reduction: X-Ray and Neuro-Vascular status evaluation is mandatory 1. Hip Dislocation Description - Traumatic hip dislocation of the hip joint may occur with or without fracture of the acetabulum of the proximal end of the femur.
Other authors define community prevention as all activities carried out in the community setting that stimulate the participation of community representatives or institutions (e generic cytotec 200 mcg visa jnc 8 medications. The community context offers a wide range of actuation that can be defined by exclusion from other areas purchase cytotec 200 mcg mastercard medicine grapefruit interaction; and therefore, it encompasses everything that is not reserved for more specific areas such as school, family or workplace, to cite the most common areas. One might include the following as the main settings of actuation for community prevention: recreational night life, media, 18 Daniel Lloret Irles and José Pedro Espada Sánchez public urban spaces and public facilities. Developed within these areas are preventive interventions aimed at promoting healthy lifestyles and reducing the influence of those social conditions likely to cause damage, discomfort or tension. Although the legal framework implies a differentiating element, similar preventive principles apply in both cases and the measures and techniques used are aimed at reducing the availability and fostering a social attitude against substance use. Typology of Community Level Prevention Programs The community context provides an extensive panorama of possibilities for intervention. The range of social segments that are accessible through the community context, the emergence of new supports and the definition of new objectives, make attempts to classify the variety of channels and formats used by community prevention inscrutable. A possible classification could be the classic primary, secondary and tertiary one that takes into account the relationship of the target population with drug use. From this perspective, interventions are organized into three levels: universal, selective or indicated. Taking as criterion the format adopted by the program or preventive intervention and the medium used to reach the target population, we arrive at one of the possible classifications which, like any other, contain a certain degree of overlap that make it inexact. According to this criterion, we can sort interventions into four types: a) Interventions through the media. Interventions through the Media Interventions in the media adopt many different formats ranging from short and repeated messages –advertising spots-to more elaborate areas such as reports and interviews. This type of intervention aims to inform and encourage individuals towards a reflection aimed at abstinence, while reinforcing the various prevention actions and programs carried out in specific spheres and the communicative actions launched from the various social communication supports. As with other types of actions, their effectiveness is enhanced when coordinated with more structured prevention programs. There is sufficient evidence on the effectiveness of brief interventions in the media (Derzon and Lipsey, 2002, Longshore, Ghosh-Dastidar and Ellickson, 2003). Analysis of the assessment of the effectiveness of preventive ad exposure concluded a reduction in the likelihood of marijuana, crack and cocaine consumption (Block, Morwitz, Putsis and Sen, 2002). Apart from the content of preventive messages, it becomes necessary to revise the traditional formats of these messages designed for classical media supports (i. The new information and communication technologies offer the possibility to participate in communicative discourse, which increases audience involvement. Empirical evidence maintains that prevention programs that include dynamic and participatory components are more effective than those based on the mere transmission of information. Internet: A new support, a new generation of continuous change Within the broad field of care and prevention of problems arising from drug use, the Internet is turning out to be a breakthrough; since, it facilitates the exchange of knowledge and experience among professionals on the one hand, and on the other the implementation of on-line preventive programs destined for society in general. In this way, the Internet can serve as a medium in which 20 Daniel Lloret Irles and José Pedro Espada Sánchez particular preventive programs are developed, or it can also be a support tool at the service of teachers within the educational framework and parents within the bosom of the family. Prevention programs with the format of web pages provide information, data, and actuation models and offer the following advantages over a traditional format (Lacoste et al. It is an interactive medium that turns the final recipient of the message into a co-author, because he or she can actively collaborate by providing and/or modifying content. It is the communication channel used by young people today, and it will be the form of communication of upcoming generations. Browsing the Internet and feeling part of that virtual world, in which you can find everything under the sun, continues to be one of the greatest attractions of this communication technology. This is very difficult to obtain without the speed and immediacy of the world of links and hypertextuality. Since the inception of the Internet, professionals concerned about public health have used the online format to inform and sensitize the public about the consequences of drug consumption or other deviant behavior. However, only since a few years ago do we find initiatives designed to reach and capture the 21 Analysis of Drug Use Prevention on a Community-wide Scale attention of a young target audience by taking their audiovisual tendencies into account (Garcia del Castillo y Segura, 2009). In this sense, we believe the productions that stand out meet the dual objectives of spreading knowledge based on scientific evidence and transmitting information as a prevention tool. Some examples are: - The Spanish Association against Cancer publishes on its website an info- graphic video on the path of tobacco smoke and its effects along its path inside the body. Mediator training programs This type of action consists of the training of mediators and leaders in the skills needed to produce a transmission of values and attitudes seeking a snowball effect. The mediator acts as a catalyst for social change processes that are considered necessary for the achievement of preventive goals. Generally, the task of the social mediator in community interventions is not to impart knowledge or direct the training process of participants, but rather to put them in a position to learn without becoming the protagonist of their learning. The mediator must be mindful of motivating, facilitating, and eliminating obstacles, clearly showing the ability of groups to solve problems, yet all without directing or offering solutions. In principle, there are a large number of social agents who can exercise the role of mediator: teachers, health 22 Daniel Lloret Irles and José Pedro Espada Sánchez or social professionals, members of religious orders, volunteers, etc. Although there is no profile that ensures optimum performance by the mediator, it seems clear that in no case be must mediators be arrogant, manipulative or incoherent, paternalistic, inflexible or rigid, or biased; neither must they consider themselves essential, nor believe that they are a savior, nor maintain closed or circular discourse. By contrast, the social mediator must show maturity and personal balance, capacity for continuous analysis of reality, critical and creative ability, knowledge of the immediate environment, capacity for teamwork, ability to manage and plan social activities, capacity to relate to the community, capacity for dialogue and communication, some psycho-pedagogic training and ability to dynamize social, group and personal life. Community action groups Community action groups are associations or nonprofit organizations formed to carry out projects of interest in the community. Often these types of social initiatives arise from the interest and motivation of a few, generally those affected by the problem to be resolved. Public interest in the group´s action and the spreading of their work permit others to join and collaborate in the effort. Created to deal with a social problem, they offer advisory assistance and social support to people who are in similar situations and participating in preventive campaigns. Other established and active groups, such as certain neighborhood associations, have taken among their objectives the fight against social scourges and also the prevention of drug dependencies. Accordingly, they have incorporated actions with preventive intentions into their repertoire of activities, which they carry out in their work environment. Plans and strategies to combat drug use commonly include objectives aimed at promoting social participation; to meet these objectives, organizations are provided with budgets to carry out preventive work. Thus, we find in the 23 Analysis of Drug Use Prevention on a Community-wide Scale current "European Union Drugs Action Plan for 2009-2012" objectives aimed at promoting citizenry participation. The fourth objective of the area of coordination reads: "Ensuring the participation of civil society in the policy against drugs". The key to a community action group´s success is having the support of opinion leaders (politicians, presidents of community or professional organizations, media publishers, etc. Also important are volunteers and supporters (especially professionals: sociologists, physicians, psychologists, social workers, the police, etc. Staff training programs for bar and disco personnel, also known as Responsible Beverage Service Programs, seek to train bartenders, waiters and other staff, including managers, in handling situations of tension and violence and the prevention of alcohol-related accidents. This type of action is not without difficulties and obstacles in its implementation; there is strong resistance on the part of owners and managers, whose cooperation is achieved only through the obligatory nature of the action. Maintaining an adequate level of training requires that a training structure be constantly maintained.
And if an artery or arteriole dilates to twice its initial radius order cytotec us treatment conjunctivitis, then resistance in the vessel will decrease to 1/16 of its original value and flow will increase 16 times purchase 100 mcg cytotec with visa medications 222. The Roles of Vessel Diameter and Total Area in Blood Flow and Blood Pressure Recall that we classified arterioles as resistance vessels, because given their small lumen, they dramatically slow the flow of blood from arteries. Notice in parts (a) and (b) that the total cross-sectional area of the body’s capillary beds is far greater than any other type of vessel. Although the diameter of an individual capillary is significantly smaller than the diameter of an arteriole, there are vastly more capillaries in the body than there are other types of blood vessels. Part (c) shows that blood pressure drops unevenly as blood travels from arteries to arterioles, capillaries, venules, and veins, and encounters greater resistance. However, the site of the most precipitous drop, and the site of greatest resistance, is the arterioles. This explains why vasodilation and vasoconstriction of arterioles play more significant roles in regulating blood pressure than do the vasodilation and vasoconstriction of other vessels. Part (d) shows that the velocity (speed) of blood flow decreases dramatically as the blood moves from arteries to arterioles to capillaries. This is a leading cause of hypertension and coronary heart disease, as it causes the heart to work harder to generate a pressure great enough to overcome the resistance. Arteriosclerosis begins with injury to the endothelium of an artery, which may be caused by irritation from high blood glucose, infection, tobacco use, excessive blood lipids, and other factors. Artery walls that are constantly stressed by blood flowing at high pressure are also more likely to be injured—which means that hypertension can promote arteriosclerosis, as well as result from it. Moreover, circulating triglycerides and cholesterol can seep between the damaged lining cells and become trapped within the artery wall, where they are frequently joined by leukocytes, calcium, and cellular debris. The term for this condition, atherosclerosis (athero- = “porridge”) describes the mealy deposits (Figure 20. This clot can further obstruct the artery and—if it occurs in a coronary or cerebral artery—cause a sudden heart attack or stroke. Alternatively, plaque can break off and travel through the bloodstream as an embolus until it blocks a more distant, smaller artery. Even without total blockage, vessel narrowing leads to ischemia—reduced blood flow—to the tissue region “downstream” of the narrowed vessel. Hypoxia involving cardiac muscle or brain tissue can lead to cell death and severe impairment of brain or heart function. A major risk factor for both arteriosclerosis and atherosclerosis is advanced age, as the conditions tend to progress over time. Arteriosclerosis is normally defined as the more generalized loss of compliance, “hardening of the arteries,” 908 Chapter 20 | The Cardiovascular System: Blood Vessels and Circulation whereas atherosclerosis is a more specific term for the build-up of plaque in the walls of the vessel and is a specific type of arteriosclerosis. There is also a distinct genetic component, and pre-existing hypertension and/or diabetes also greatly increase the risk. However, obesity, poor nutrition, lack of physical activity, and tobacco use all are major risk factors. Treatment includes lifestyle changes, such as weight loss, smoking cessation, regular exercise, and adoption of a diet low in sodium and saturated fats. In angioplasty, a catheter is inserted into the vessel at the point of narrowing, and a second catheter with a balloon-like tip is inflated to widen the opening. This operation is typically performed on the carotid arteries of the neck, which are a prime source of oxygenated blood for the brain. In a coronary bypass procedure, a non-vital superficial vessel from another part of the body (often the great saphenous vein) or a synthetic vessel is inserted to create a path around the blocked area of a coronary artery. Venous System The pumping action of the heart propels the blood into the arteries, from an area of higher pressure toward an area of lower pressure. If blood is to flow from the veins back into the heart, the pressure in the veins must be greater than the pressure in the atria of the heart. First, the pressure in the atria during diastole is very low, often approaching zero when the atria are relaxed (atrial diastole). Skeletal Muscle Pump In many body regions, the pressure within the veins can be increased by the contraction of the surrounding skeletal muscle. As leg muscles contract, for example during walking or running, they exert pressure on nearby veins with their numerous one-way valves. This increased pressure causes blood to flow upward, opening valves superior to the contracting muscles so blood flows through. Simultaneously, valves inferior to the contracting muscles close; thus, blood should not seep back downward toward the feet. Military recruits are trained to flex their legs slightly while standing at attention for prolonged periods. Consequently, the brain will not receive enough oxygenated blood, and the individual may lose consciousness. During inhalation, the volume of the thorax increases, largely through the contraction of the diaphragm, which moves downward and compresses the abdominal cavity. The elevation of the chest caused by the contraction of the external intercostal muscles also contributes to the increased volume of the thorax. Additionally, as air pressure within the thorax drops, blood pressure in the thoracic veins also decreases, falling below the pressure in the abdominal veins. This causes blood to flow along its pressure gradient from veins outside the thorax, where pressure is higher, into the thoracic region, where pressure is now lower. During exhalation, when air pressure increases within the thoracic cavity, pressure in the thoracic veins increases, speeding blood flow into the heart while valves in the veins prevent blood from flowing backward from the thoracic and abdominal veins. Pressure Relationships in the Venous System Although vessel diameter increases from the smaller venules to the larger veins and eventually to the venae cavae (singular = vena cava), the total cross-sectional area actually decreases (see Figure 20. The individual veins are larger in diameter than the venules, but their total number is much lower, so their total cross-sectional area is also lower. Also notice that, as blood moves from venules to veins, the average blood pressure drops (see Figure 20. Again, the presence of one-way valves and the skeletal muscle and respiratory pumps contribute to this increased flow. Since approximately 64 percent of the total blood volume resides in systemic veins, any action that increases the flow of blood through the veins will increase venous return to the heart. Maintaining vascular tone within the veins prevents the veins from merely distending, dampening the flow of blood, and as you will see, vasoconstriction actually enhances the flow. The Role of Venoconstriction in Resistance, Blood Pressure, and Flow As previously discussed, vasoconstriction of an artery or arteriole decreases the radius, increasing resistance and pressure, but decreasing flow. The walls of veins are thin but irregular; thus, when the smooth muscle in those walls constricts, the lumen becomes more rounded. The more rounded the lumen, the less surface area the blood encounters, and the less resistance the vessel offers. Vasoconstriction increases pressure within a vein as it does in an artery, but in veins, the increased pressure increases flow. Recall that the pressure in the atria, into which the venous blood will flow, is very low, approaching zero for at least part of the relaxation phase 910 Chapter 20 | The Cardiovascular System: Blood Vessels and Circulation of the cardiac cycle. Another way of stating this is that venoconstriction increases the preload or stretch of the cardiac muscle and increases contraction. Small molecules, such as gases, lipids, and lipid-soluble molecules, can diffuse directly through the membranes of the endothelial cells of the capillary wall.
Clinical Uses: Erythromycin is the drug of choice in corynebacterial infections (diphtheria discount 100 mcg cytotec fast delivery treatment 5 alpha reductase deficiency, corynebacterial sepsis order online cytotec treatment bacterial vaginosis, erythrasma); in respiratory, neonatal, ocular, or genital chlamydial infections; and in treatment of community-acquired pneumonia because its spectrum of activity includes the pneumococcus, Mycoplasma, and Legionella. Erythromycin is also useful as a penicillin substitute in penicillin-allergic individuals with infections caused by staphylococci, streptococci, or pneumococci. Adverse Reactions Gastrointestinal Effects: Anorexia, nausea, vomiting, and diarrhea. Liver Toxicity: Erythromycins, particularly the estolate, can produce acute cholestatic hepatitis (reversibile). It increases serum concentrations of oral digoxin by increasing its bioavailability. Clarithromycin and erythromycin are virtually identical with respect to antibacterial activity except that clarithromycin has high activity against H. Clarithromycin penetrates most tissues, with concentrations equal to or exceeding serum concentrations. The advantages of clarithromycin compared with erythromycin are lower frequency of gastrointestinal intolerance and less frequent dosing. Azithromycin The spectrum of activity and clinical uses of azithromycin is identical to those of clarithromycin. Clindamycin Clindamycin is active against streptococci, staphylococci, bacteroides species and other anaerobes, both grampositive and gram-negative. Clinical uses: Clindamycin is used for the treatment of severe anaerobic infection caused by Bacteroides. It is used for prophylaxis of endocarditis in patients with valvular heart disease who are undergoing certain dental procedures. Clindamycin plus primaquine is an effective for moderate to moderately severe Pneumocystis carinii pneumonia. Adverse effects: Diarrheas, nausea, and skin rashes, impaired liver functions are common. Severe diarrhea and enterocolitis is caused by toxigenic C difficile (infrequently part of the normal fecal flora but is selected out during administration of oral antibiotics). Pharmacokinetics: Aminoglycosides are absorbed very poorly from the intact gastrointestinal tract. The kidney clears aminoglycosides, and excretion is directly proportionate to creatinine clearance. Ototoxicity can manifest itself either as auditory damage, resulting in tinnitus and high-frequency hearing loss initially; or as vestibular damage, evident by vertigo, ataxia, and loss of balance. Nephrotoxicity results in rising serum creatinine levels or reduced creatinine clearance. Streptomycin Streptomycin is mainly used as a first-line agent for treatment of tuberculosis. Adverse Reactions: Disturbance of vestibular function (vertigo, loss of balance) is common. The frequency and severity of this disturbance are proportionate to the age of the patient, the blood levels of the drug, and the duration of administration. Vestibular dysfunction may follow a few weeks of unusually high blood levels or months of relatively low blood levels. Gentamicin Gentamicin inhibits many strains of staphylococci and coliforms and other gram-negative bacteria. It is a synergistic companion with beta-lactam antibiotics, against Pseudomonas, Proteus, Enterobacter, Klebsiella, Serratia, Stenotrophomonas, and other gram-negative rods that may be resistant to multiple other antibiotics. Gentamicin is also used concurrently with penicillin G for bactericidal activity in endocarditis due to viridans streptococci. Creams, ointments, or solutions gentamicin sulfate are for the treatment of infected burns, wounds, or skin lesions. It is resistant to many enzymes that inactivate gentamicin and tobramycin, and it therefore can be employed against some microorganisms resistant to the latter drugs. Strains of multidrug- resistant Mycobacterium tuberculosis, including streptomycin-resistant strains, are usually susceptible to amikacin. Kanamycin, Neomycin, Paromomycin These drugs are closely related is also a member of this group. Neomycin and kanamycin are too toxic for parenteral use and are now limited to topical and oral use. In hepatic coma, the coliform flora can be suppressed for prolonged periods by giving 1 g every 6-8 hours together with reduced protein intake, thus reducing ammonia intoxication. Spectinomycin Spectinomycin is an aminocyclitol antibiotic that is structurally related to aminoglycosides. Spectinomycin is used almost solely as an alternative treatment for gonorrhea in patients who are allergic to penicillin or whose gonococci are resistant to other drugs. Nucleic Acid Synthesis Inhibitors Nalidixic acid Nalidixic acid is the first antibacterial quinolone. It is not fluorinated and is excreted too rapidly to have systemic antibacterial effects. Because of their relatively weak antibacterial activity, these agents were useful only for the treatment of urinary tract infections and shigellosis. Fluoroquinolones Quinolones are synthetic fluorinated analogs of nalidixic acid, that nucleic acid synthesis. Ofloxacin and ciprofloxacin inhibit gram-negative cocci and bacilli, including Enterobacteriaceae, Pseudomonas, Neisseria, Haemophilus, and Campylobacter. Intracellular pathogens such as Legionella, Chlamydia, M tuberculosis and M avium complex, are inhibited by fluoroquinolones. The fluoroquinolones are excreted mainly by tubular secretion and by glomerular filtration. Clinical Uses: Fluoroquinolones are effective in urinary tract infections even when caused by multidrug-resistant bacteria, eg, Pseudomonas. Norfloxacin 400 mg, ciprofloxacin 500 mg, and ofloxacin 400 mg given orally twice daily and all are effective. These agents are also effective for bacterial diarrhea caused by Shigella, Salmonella, toxigenic E coli, or Campylobacter. Fluoroquinolones (except norfloxacin, which does not achieve adequate systemic concentrations) have been employed in infections of soft tissues, bones, and joints and in intra- abdominal and respiratory tract infections, including those caused by multidrug-resistant organisms such as Pseudomonas and Enterobacter. Ciprofloxacin and ofloxacin are effective for gonococcal infection, including disseminated disease, and ofloxacin is effective for chlamydial urethritis or cervicitis. Concomitant administration of theophylline and quinolones can lead to elevated levels of theophylline with the risk of toxic effects, especially seizures. Thus, they are not routinely recommended for use in patients under 18 years of age. Since fluoroquinolones are excreted in breast milk, they are contraindicated for nursing mothers. It is well absorbed after oral administration and excreted mainly through the liver into bile.