By A. Kulak. California State University, Sacramento.

O2-Hb dissociation curve: Each molecule of Hb binds to 4 molecules of O2 purchase loratadine online from canada, which is 100% saturation generic loratadine 10 mg. If 3 molecules of O2 bind - 75% saturation If 2 “ “ “ “ - 50% “ if 1 “ “ “ “ - 25% “ 248 Figure 67 order generic loratadine. Binding first molecule of O2 to a heme group increases the affinity for the second O2 molecule, the second to the third. The graph shown in figure 68 corresponds to 100% saturation and (affinity of Hg for O2 highest). Due to positive coaperativity, affinity of Hb for O2 is the highest, which corresponds to flat portion of curve (figure 68). Changes in the O2-Hb dissociation curve: Shift to the right: Occur when there is decreased affinity of Hb for O2 (see figure. Increases in temperature also cause right shift, and facilitate unloading of oxygen in the tissues. This decrease in affinity causes right shift and facilitates unloading of oxygen in the tissues. This facilitates O2 delivery to the tissues as adaptive mechanism 252 Figure 69 A. By the time blood reaches the venous end of the capillaries Hb is conveniently in its deoxygenated form (i. There is a useful + reciprocal relationship between the buffering of H by deoxyhemoglobin and the Bohr + effect. Thus the H generated from the tissue Co2 causes hemoglobin to release O2 + more readily to the tissues. The frequency of normal, involuntary breathing is controlled by three groups of neurons or brainstem centers. Afferent (sensory) information reaches the medullary inspiratory center Via central and peripheral chemoreceptors and via 259 mechanoreceptor. Efferent (motor) information is sent from inspiratory center to the phrenic nerve, which innervates the diaphram. Inspiration is shortened by inhibition of inspiratory center via the pneumotaxic center (see below) • Expiratory center (see figure 68) is located in the ventral respiratory neurons and is responsible primarily for expiration. Since expiration is normally a passive process, these neurons are inactive during quite breathing. However, during exercise when expiration becomes active, this center is activated • Apneustic Center. Apneusis is an abnormal breathing pattern with prolonged inspiratory gasps, followed by brief expiratory movement. Stimulation of apneustic center in the lower pons excites the inspiratory center in the medulla, prolonging the contraction of the phrenic nerve. Normal breathing rhythm persists in the absence of these centers Cerebral cortex: Commands from the cerebral cortex can temporarily override automatic brainstem centers. The decrease in PaCo2 will produce unconsciousness and person revert to normal breathing pattern. Central chemoreceptors: They are located in the brain stem (ventral surface of medulla) and are important for minute-to-minute control of breathing. Other receptors: Lung stretch receptors: These are mechanoreceptor in smooth muscle of the airways. Joint and muscle receptors: They are located in joints and muscles and detect movement of limbs. Instruction is given to the inspiratory centers to increase breathing rate Irritant receptors: Their location is between epithelial cells lining the airway. They are stimulated by noxious chemicals and particles The response is reflex constriction of bronchial smooth muscles and increase in breathing rate J- Receptors (Juxtacapillery receptors): These receptors are found in the alveolar walls (thus near capillaries). The stimulus is engorgement of pulmonary capillaries with blood and increase in interstitial fluid volume. The response is increase in breathing rate For example, in left heart failure blood “backs up” in pulmonary circulation, and J receptors mediate change in breathing pattern including rapid shallow breathing and dyspnea (difficulty in breathing) General and Cellular nonrespiratory lung function Filtration: filter out small blood clots (small pulmonary emboli) Immunologic: bronchial secretion contains Immuno globulin ( IgA ) Alveolar macrophages are phagocytic and remove bacteria and small particles inhaled by lungs. Macrophages also function in attraction of polymorpho nuclear leukocytes, release Vasoactive and chemo tactic substances. In less severe degree it results: (1) Depressed mental activity, sometimes culminating in coma. As a result, or O2 is extracted from the blood to support the oxidative metabolism of the tissues. Examples - Respiratory depression due to drug overdose (barbiturate poisoning) - Severe weakness of the muscles that support respiration e. It is caused by a decrease in the amount of hemoglobin available for binding of O2 so that the O2 content of the arterial blood is abnormally low. The major reasons of anemic hypoxia are: - Reduced erythropoiesis - Blood loss - Synthesis of abnormal hemoglobin - Carbon monoxide poisoning (3) Stagnant hypoxia If the blood flow through a tissue is sluggish, blood would stay in the capillaries for a longer time than the normal. Therefore, the blood will have to meet the oxygen requirements of the tissue for a longer time. The stay of blood in the capillaries may be so long that even after extracting a very large fraction of O2 carried by the blood, all the requirements of the tissue cannot be met. Examples: - Reduced cardiac output: cardiac failure, hemorrhage, circulatory shock - Local vasoconstriction: exposure of the extremities to the cold (4) Histotoxic hypoxia If the tissues are unable to use oxygen brought to them by blood, even that results in hypoxia. In this situation thesupply of O2 to the tissues is normal but they are unable to make full use of it. Examples: - Cyanide poisoning - Beriberi Oxygen therapy Oxygen therapy may be required for respiratory failure due to lung disease or poisoning. Methods of oxygen administration Oxygen may be administered in many ways: (1) Cannula (intranasal tube) The simplest way is to connect a cannula to an oxygen cylinder and insert it into one or both nostrils. This raises the concentration of oxygen in the inspired air but generally not to 100%, which may be a boon if the hypoxic drive is important to maintain the ventilation of the patient. Patients who remain unconscious for fairly long periods of long time are given an endotracheal or tracheostomy tube, which are connected to a ventilator. Effectiveness of hypoxia in different types of hypoxia Oxygen therapy is very useful in some types of hypoxia, may have some value in some types, whereas, in some cases it is not useful at all. This raises the oxygen pressure gradient for diffusion between the alveoli and the blood from the normal value of 60mmHg to as high as 560mmHg, an increase more than 800%. Eve so, a little amount of extra oxygen, between 7 and 30%, can be transported in the dissolve state in the blood when alveolar oxygen is increased to maximum even though the amount transported by the hemoglobin is hardly altered. Cyanosis The term cyanosis means blueness of the skin, and its cause is excessive amounts of deoxygenated hemoglobin in the skin blood vessels, especially in the capillaries.

They were followed- pregnant patients trusted loratadine 10 mg, the elderly and up every six months throughout in patients who do not want or the 2-year intervention period cheap loratadine. The results indicated that the Pessaries may also be used to intervention was only effective in facilitate preoperative healing the group with severe prolapse discount loratadine 10mg free shipping. Another useful 121 advantage of these devices is that to ensure that the integrity of the they can be used to elicit occult silicone is intact. The vagina should stress incontinence before surgical also be examined for signs of repair of genital prolapse. She should be aware While pessary manufacturers that it may cause some discomfort provide suggestions for different to both partners in the beginning pessary shapes to manage different but this often settles as the types of prolapse, experience patient and her partner become suggests that trial and error is comfortable with it. Women who really the only way to determine are able to remove and reinsert the best ft for each patient. Other factors, such as the patient’s physical capacity and willingness to participate in the care of the pessary, together with the size of the introitus, the patient’s weight and her physical activity also play a role when choosing a pessary. Fritzinger et al stated that there is no scientifc data outlining the A simulated picture depicting the standards of care for users of position and placement of the vaginal pessaries. However, most pessary authors agree that routine follow up of women using pessaries is necessary to minimize the risk of complications associated with Contraindications to Pessary their use. At each visit the pessary Insertion should be removed and cleaned • Severe untreated vaginal using mild antibacterial soap and atrophy warm water. It should be examined • Vaginal bleeding of unknown 122 origin remain in place • Pelvic infammatory disease • Abnormal pap smear • Dementia without possibility of dependable follow-up care • Expected non-compliance with follow-up Types of Pessaries Often referred to as the “incontinence ring” since it has been designed for use in women with stress incontinence. Complications of pessaries All authors listed vaginal discharge and odor as the most common complication. Other complications which may occur are pelvic pain, Arch Heel Gehrung bleeding and development of • U-shaped device that provides urinary incontinence. The heel rests fat on the or failure of the pessary to vaginal foor hold the prolapse properly is • It avoids pressure on the rectum an obvious disadvantage. They state that early intervention using an estrogen-based cream or vaginal lubricant are essential to proper pessary care. Severe complications such as vesico-vaginal fstulae, hydronephrosis, sepsis, and even 124 small bowel incarceration were cited in the literature as the result of inadequate follow-up. Conclusion There is paucity of good randomized controlled trails that evaluate the use of conservative methods for the management of pelvic organ prolapse. Its treatment is one of the • Associated incontinence most common surgical indications symptoms in gynaecology, accounting for • Patient’s wishes 20% of elective major surgery with this fgure increasing to 59% in Important point the elderly population. Despite There is as yet no surgical numerous modifcations to the technique that can guarantee traditional surgical techniques and 100% success in treating prolapse the recent introduction of novel and some procedures such as procedures, the permanent cure of anterior colporrhaphy carry failure urogenital prolapse remains one of rates of up to 30%. Surgical Management General principles The following factors need to All women should receive be taken into account when prophylactic antibiotics to considering surgical intervention cover gram-negative and gram for prolapse: positive organisms, as well as 126 thromboembolic prophylaxis in fascial plication. Surgical options extensive dissection stretching for Anterior from the pubis anteriorly to the Compartment ischial spine posteriorly. The underlying Through a Pfannenstiel incision, pubocervical fascia is then reduced the retropubic space is opened using vicryl 3/0 sutures, known as and the bladder swept medially, 127 exposing the pelvic sidewall, very at the level of the hymenal similar to a burch colposuspension remnants, allowing the calibre procedure. The rectocele is mobilized pubis to just anterior to the ischial from the vaginal skin by blunt and spine. The rectovaginal fascia is then plicated using either an interrupted or continuous absorbable suture (Vicryl 3/0), to 2. Care Compartment should be taken not to create a Prolapse constriction ring in the vagina which will result in dyspareunia. Traditionally this compartment The redundant skin edges are is approached vaginally when then trimmed taking care not to operated on by the gynaecologist. The posterior that the colo-rectal surgeons vaginal wall is closed with a also operate on the posterior continuous Vicryl 2/0 suture. The patient should be specifc plication, place a number referred to a colorectal surgeon of interrupted lateral sutures for assessment if the following are that incorporate the Levator Ani present: concurrent anal or rectal muscles. This Levator plication has pathology such as hemorrhoids, been shown to be associated with rectal wall prolapse or rectal signifcant dyspareunia and is no mucosal redundancy. Finally a perineorrhaphy is performed by placing deeper absorbable sutures Posterior Colpoperineorrhaphy into the perineal muscles and Procedure fascia thus building up the perineal Two allis or littlewood forceps body to provide additional support are placed on the perineum 128 to the posterior vaginal wall and uterosacral ligament sutures are lengthening the vagina. Injury to therefore tied in the midline and the rectum is unusual but should brought through the posterior be identifed at the time of the part of the vault and tied after procedure so that the defect the vault has been closed. Middle the ureters at risk and therefore ureteric patency should be Compartment confrmed post-operatively by cystoscopy. This is a purse- string suture that goes through The cervix is circumscribed and the both corners of the vaginal vault, utero-vesical fold and pouch of through the uterosacral ligaments Douglas opened. The uterosacral and also through the posterior and cardinal ligaments are divided peritoneum to obliterate the and ligated frst, followed by the pouch of Douglas to prevent uterine pedicles and fnally the enterocele formation. The most (See a separate chapter on important part of the procedure Sacrocolpopexy) is support of the vault since these women are at high risk for post- This technique involves hysterectomy vault prolapse. It is not attached to the anterior aspect essential to open the enterocele of the sacral promontory using sac although care should be taken either an Ethibond suture or screw not to damage any loops of small tacks. The operation The vaginal vault can be supported has fallen from favour as long vaginally or abdominally. Both right and Modifed McCall cul-de-plasty (Endopelvic left Sacrospinous ligaments can fascia repair) be used to support the vagina. Iliococcygeus fascia fxation Some surgeons employ only one ligament but there is no evidence High uterosacral ligament suspension with fascial reconstruction to suggest that a uni-or bilateral is better. Vaginal obliterative procedures Colpectomy & colpocleisis Care must be taken to avoid Abdominal procedures that suspend the the sacral plexus and sciatic apex nerve which are superior to the Sacralcolpopexy ligament, and the pudendal New techniques vessels and nerve which are lateral to the ischial spine. The Transobturator- procedures including Prolift, Apogee and Avaulta sacrospinous sutures are then tied to support the vaginal vault 3. Success rates for this to expose the ischial spine using procedure are in the region of 80- sharp and blunt dissection. A standard • Stress incontinence long needle holder or a specially • Vaginal stenosis designed Miya hook ligature • Anterior vaginal wall prolapse carrier can be used. These raw areas are is fxed to the illiococcygeus muscle then sutured together, thereby fascia on both sides, just anterior burying the cervix and obliterating to the ischial spines. In total colpocleisis all can be performed through either the vaginal skin is removed and an anterior or posterior vaginal the anterior and posterior vaginal incision. In both suture is used and secured to the these procedures, an aggressive vaginal vault and is associated perineorrhaphy is performed. A trial following these procedures and comparing illiococcygeus fxation therefore a concomitant mid- and sacrospinous fxation found urethral tape is mandatory.

Person specific attack rates: The tool that is important for the analysis of disease outbreaks by personal characteristics is person specific attack rates like attack rates by age buy generic loratadine 10 mg on line, sex 10 mg loratadine visa, occupation discount loratadine 10mg with amex, income, religion etc. Identify the causes of the epidemic All factors that can contribute to the occurrence of the epidemic should be assessed. In addition to knowing the etiologic agent, more emphasis should be given to identify the risk factors. Investigate the environmental conditions such as food sanitation, suspected breeding sites, animal reservoirs, according to the type of disease outbreak being investigated. Management of epidemic and follow up Although it is discussed late, intervention must start as soon as possible depending on the specific circumstances. For example, an outbreak might be controlled by destroying contaminated foods, disinfecting contaminated water, or destroying mosquito breeding sites or an infectious food handler could be suspended from the job and treated. General principles in the management of epidemics Management of epidemics requires an urgent and intelligent use of appropriate measures against the spread of the disease. However, the actions can be generally categorized as presented below to facilitate easy understanding of the strategies. Measures Directed Against the Reservoir 62 Understanding the nature of the reservoir is necessary in the selection of an appropriate control methods and their likelihood of success. The following are examples of control measures against diseases with various reservoirs: Domestic animals as reservoir: Immunization. This is not suitable in the control of diseases in which a large proportion are inapparent infection (without signs and symptoms) or in which maximal infectivity precedes overt illness. Quarantine- is the limitation of freedom of movement of apparently healthy persons or animals who have been exposed to a case of infectious disease. Cholera, Plague, and yellow fever are the three internationally quarantinable diseases by international agreement. Now quarantine is replaced in some countries by active surveillance of the individuals; maintaining close supervision over possible contacts of ill persons to detect infection or illness promptly; their freedom of movement is not restricted. Measures that interrupt the transmission of organisms Action to prevent transmission of disease by ingestion: i. Example vaccination for meningitis Chemoprophylaxis: for example, use of chloroquine to persons traveling to malaria endemic areas. After the epidemic is controlled, strict follow up mechanisms should be designed so as to prevent similar epidemics in the future. Report of the investigation At the end prepare a comprehensive report and submit to the appropriate/concerned bodies like the Woreda Health Office. The report should follow the usual scientific format: introduction, methods, results, discussion, and recommendations. Passive surveillance Passive surveillance may be defined as a mechanism for routine surveillance based on passive case detection and on the routine recording and reporting system. The information provider comes to the health institutions for help, be it medical or other preventive and promotive health services. Advantages of passive surveillance covers a wide range of problems does not require special arrangement it is relatively cheap 69 covers a wider area The disadvantages of passive surveillance The information generated is to a large extent unreliable, incomplete and inaccurate Most of the time, data from passive surveillance is not available on time Most of the time, you may not get the kind of information you desire It lacks representativeness of the whole population since passive surveillance is mainly based on health institution reports Active surveillance Active surveillance is defined as a method of data collection usually on a specific disease, for relatively limited period of time. It involves collection of data from communities such as in house-to-house surveys or mobilizing communities to some central point where data can be collected. This can be arranged by assigning health personnel to collect information on presence or absence of new cases of a particular disease at regular intervals. Example: investigation of out-breaks 70 The advantages of active surveillance the collected data is complete and accurate information collected is timely. The disadvantages of active surveillance it requires good organization, it is expensive it requires skilled human power it is for short period of time(not a continuous process) it is directed towards specific disease conditions Conditions in which active surveillance is appropriate Active surveillance has limited scope. These conditions are: For periodic evaluation of an ongoing program For programs with limited time of operation such as eradication program 71 In unusual situations such as: New disease discovery New mode of transmission When a disease is found to affect a new subgroup of the population. In this strategy several activities from the different vertical programs are coordinated and streamlined in order to make best use of scarce resources. The activities are combined taking advantage of similar surveillance functions, skills, resources, and target population. Integrated disease surveillance strategy recommends coordination and integration of surveillance activities for diseases of public health importance. Diseases included in the integrated disease surveillance system Among the most prevalent health problems 21 (twenty one) communicable diseases and conditions are selected for integrated disease surveillance to be implemented in Ethiopia. Epidemic-Prone Diseases 74 Cholera Diarrhea with blood (Shigella) Yellow fever Measles Meningitis Plague Viral hemorrhagic fevers*** Typhoid fever Relapsing fever Epidemic typhus Malaria B. Principles and Practice of Public Health Surveillance, second edition, Oxford University Press, Oxford, 2000. They are intended to provide the clinician, especially trainees, easy access to basic information needed in day-to-day decision-making and care. Grade A One (or more) mucosal breaks no longer than 5 mm that do not extend between the tops of two mucosal folds. Grade B One (or more) mucosal breaks more than 5 mm long that do not extend between the tops of two mucosal folds. Grade C One (or more) mucosal breaks that are continuous between the tops of two or more mucosal folds but involve <75% of the esophageal circumference. All newly diagnosed cirrhotics and all other cirrhotics who are medically stable, willing to be treated prophylactically, and would benefit from medical or endoscopic therapies. Secondary prophylaxis -Beta-blockers: Meta-analyses suggest that the risk of bleeding is decreased by 40%, the risk of death by 20%. Inject air through the gastric suction port and auscultate over the stomach (for presumptive evident that the tube has been properly inserted). Use of a pulley-weight system traction on the tube is discouraged because if the gastric balloon should deflate, the esophageal balloon (if inflated) could be pulled up and obstruct the airway. Monitor the pressure in the esophageal balloon by attaching its port to a sphygmomanometer; check pressure every 30-60 minutes. Removal of the tube Do not leave either the gastric or the esophageal balloon continually inflated for more than 24 hours! Before endoscopy: two doses of 40 or 80 mg permitted After endoscopy: may be used for bleeding duodenal or gastric ulcer at 8mg/hr gtt.

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