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P was established (revised programme) Notification all cases (rate) 423 /100 purchase confido 60caps,000 Year of Rifampicin introduction 1979 Estimated incidence (all cases) 530 /100 generic 60 caps confido amex,000 Year of Isoniazid introduction 1968 Notification new sputum smear + 6455 Use of Standardized Regimens Yes Notification new sputum smear + (rate) 228 /100 buy 60 caps confido otc,000 % Use of Short Course Chemotherapy Yes 100 % Treatment Success 69 order genuine confido on line. P was established (revised programme) Notification all cases (rate) 632 /100,000 Year of Rifampicin introduction 1979 Estimated incidence (all cases) 932 /100,000 Year of Isoniazid introduction 1968 Notification new sputum smear + 15264 Use of Standardized Regimens Yes Notification new sputum smear + (rate) 359 /100,000 % Use of Short Course Chemotherapy Yes 100 % Treatment Success 70. P was established 1953 Notification all cases (rate) 6 /100,000 Year of Rifampicin introduction 1971 Estimated incidence (all cases) 5. The document may, however, be freely reviewed, abstracted, reproduced and translated, in part or in whole, but not for sale or for use in conjunction with commercial purposes. The views expressed in documents by named authors are solely the responsibility of those authors. Migliori, Dr Giorgio Besozzi, Dr Antonio Cassone, Dr Graziella Orefici, Dr Lanfranco Fattorini, Dr Elisabetta Iona • Latvia: Dr Janis Leimans, Dr Vaira Leimane, Dr Dace Mihalovska, Dr Sven Hoffner • Malaysia: Dr Iyawoo Kuppusamy, Dr Denis Padmini, Ms Soshila Ramayah, Dr Chyoji Abe • Mexico: Dr Adalberto Santaella-Solis, Dr Susana Balandrano Campos, Dr Ana Flisser Steinbruch, Dr Reuben Granich, Dr Nancy Binkin • Morocco: Dr Salah-Eddine Ottmani, Dr Jaouad Mahjour, Dr Fadila Boulahbal, Dr Pierre Chaulet • Mozambique: Dr Alfredo MacArthur Jr. Lambregts-van Weezenbeek, Dr Nico Kalisvaart • New Caledonia: Dr Philippe Duval, Dr Fadila Boulahbal • New Zealand: Dr Maggie Brett, Dr Ross Vaughan, Dr Mary Carr, Dr Catherine Tocker • Nicaragua: Dr Luis Chacon, Dr José Ramón Cruz, Dr Adalbert Laszlo, Dr Ana Reniero • Norway: Dr Einar Heldal, Dr Nanne Brattås, Dr Per Sandven • Oman: Dr Ali Ahmed Ba Omar, Dr Salah Al- Awan, Dr Suleiman AlBusaidy, Mr Jacob George, Dr Fadila Boulahbal • Peru: Ms Lucy Vàsquez Campos, Dr Jaime Portocarrero Céliz, Dr Pedro G. Suarez, Dr Ana Reniero • Poland: Prof Zofia Zwolska, Prof Kazimierz Roszkowski, Dr Bert van Klingeren • Puerto Rico: Dr Olga Joglar, Dr Ida Onorato, Dr Eugene McCray • Republic of Korea: Dr Sang Jae Kim, Dr Gill-Han Bai • Russian Federation (Ivanovo Oblast): Prof Alexander G. Stoyunin, Dr Natalia Katulina, Dr Irina Danilova, Dr Valentina Golyshevskaya • Russian Federation (Tomsk Oblast): Dr Alex Sloutsky, Dr Alex Goldfarb, Dr Tim Healing, Dr Michael Kimerling • Sierra Leone: Dr Lars Westman, Mr Abu G. George, Dr Gisela Bretzel • Singapore: Dr Jane Yap, Dr Ian Snodgrass, Dr Chyoji Abe • Slovakia: Dr Mária Svejnochová, Dr Eva Rajecová, Prof Ladislav Chovan, Dr Marta Havelková • Slovenia: Mag Manca ëolnir-Dov‹, Dr Jurij áorli, Dr Damijan Erìen, Dr Sabine Rüsch-Gerdes • South Africa: Dr Karin Weyer • Spain (Barcelona): Dr Nuria Martin-Casabona • Sweden: Dr Gunilla Källenius, Dr Sven Hoffner, Dr Victoria Romanus • Switzerland: Dr Peter Helbling, Dr Gaby E. This project could not have succeeded without the support of national authorities and the institutions hosting each of the national and international laboratories. Mr Mark Fussell, Dr Tom Frieden, Dr Jacob Kumaresan, and Dr Paul Nunn provided useful comments. The secretarial assistance of Ms Cora Dolores and Ms Zahra Ali-Piazza is also recognized. It gives the results of the survey conducted between 1996 and 1999, three years after the first survey, with the aim at collecting worldwide information on drug resistance of Mycobacterium tuberculosis. It is a great step forward compared with the information of the first survey collect- ed from 35 geographical settings. Without their intensive and meticulous work, the survey would not have been possible. It is therefore my duty and my pleasure to recognise their work and to congratulate them. They provided the key information on previous history of drug treatment that permits to classify the patients as new cases if they had no previous history of treatment; and as previ- ously treated cases if they had previous history of treatment, in other words if they have failed to be cured after one or several episodes of therapy. The distinction is of crucial im- portance because it is well known for the last fifty years that failure to be cured is often as- sociated with, if not caused by the selection of drug resistant mutants, high prevalence of drug resistance being the main characteristic of previously treated patients. Failing to iden- tify those previously treated patients among all patients would result in confused informa- tion on drug resistance in a given setting. The collection of reliable clinical data is therefore essential for surveys on drug resistance. In addition, it is intimately linked with the sam- pling of the patients to be included in the survey. To prevent, or at least limit, the possible bias in sampling, two suggestions might be made: first, to collect prospectively and not ret- rospectively the clinical information; second, to enrol consecutive patients and not to enrol separately new cases and previously treated cases. Doing so would provide the proportion of previously treated patients among the tuberculosis patients, an essential indicator for the quality of the control programme in a given population. In the present report, the read- ers might be amazed by the decision to abandon the terms "primary" and "acquired" drug resistance. Despite the well accepted definition of primary drug resistance as resistance of a strain isolated from a patient who has never been treated with anti-tuberculosis drugs, we should recognise the extreme diffi- culty to ascertain the absence of previous treatment. Thus, the term "resistance among new cases of tuberculosis" has been preferred to primary resistance. This is not a revolutionary change but the choice of a more objective and less interpretative definition. Every one would agree that a patient who fails anti-tuberculosis therapy is likely to have acquired drug resistance. But how to be certain without performing drug susceptibility test on each initial isolate that the patient strain was fully susceptible at the initiation of treatment? Systematic drug susceptibility testing being neither recommended nor possible in a majori- ty of settings, the initial susceptibility of the patient strain is usually unknown, and the re- sistance observed in case of treatment failure might be due to either "primary" or "acquired" resistance, or to a mixture of both. In order not to interpret the drug resistance found in a previously treated patient as resulting only from its previous treatment, the term "resistance in previously treated patients" has been chosen. Again, it is not a revolutionary choice but it leads to a more objective and less interpretative definition of drug resistance in previously treated patients. This report presented data from 35 geographical set- tings* (surveyed between 1994 and 1996) using standard epidemiological and laboratory guidelines. The first report of the Global Project showed that drug-resistant Mycobacterium tuber- culosis (M. Trends in drug resistance could not be evaluated in the first phase of the Global Project, as only one data point from the 35 geographical settings surveyed was available. Thus, the need to expand surveillance to other geographical settings and to continue the monitoring of settings already covered for the assessment of trends of drug resistance was considered high priority. This second report of the Global Project describes the progress of this international collaborative effort. This report contains data from 72 geographical settings involved in the Global Project between 1994 and 1999. These data are distributed as follows: i) information collected in the period 1996–1999 on the prevalence of drug resistance from 58 geographical settings; ii) trends on drug resistance from 28 geographical settings, 20 of which were originally in- cluded in the first report; iii) data from 17 geographical settings on the levels of drug resistance according to place of birth; iv) individual patient data from 11 geographical settings to assess determinants of drug resistance; vi) ecological data from all 72 geographical settings that have participated in the Global Project since 1994. The terms “primary” and “acquired” drug resistance are no longer used in this report. However, increasingly there were suggestions to abandon their use because of the difficulty to determine the exact na- ture of drug resistance. Acquired drug resistance was defined as the acquisition of resis- tance to anti-tuberculosis drugs by the organisms through selective multiplication of the spontaneously emerged resistant mutant fraction of the bacterial population as a result of inadequate chemotherapy. Primary drug resistance, on the other hand, develops in patients who become infected with a resistant strain without ever having been treated with anti-tu- berculosis drugs. In daily practice, however, it is extremely difficult to assess the level of pri- mary drug resistance. For example, patients may decide not to disclose prior treatment for different reasons, thus leading to a possible overestimation of primary resistance. Also, pa- tients who fail anti-tuberculosis therapy may do so because their disease-causing strain was initially resistant and not because they “acquired” resistance during the course of treat- ment. In view of these issues, in this report the terms “primary” and “acquired drug resis- tance” have been abandoned. Instead, the terms “resistance among new cases” and “resis- tance among previously treated cases” are used. The term “previously treated cases” refers to patients who have re- ceived at least one month of anti-tuberculosis therapy in the past. Previously treated cases include relapses, treatment failures, patients returning after defaulting, and chronic cases. In order to prevent misclassification of previously treated cases as new cases, double-check- ing of the patients’ histories, combined with a thorough review of their medical records, is es- sential. A new coordinating centre of the network was appoint- ed in 1999 at The Prince Leopold Institute of Tropical Medicine, Antwerp, Belgium. Also, sever- al geographical settings have completed at least two surveys and others perform continuous surveillance. The last surveillance data point of each geo- graphical setting was used, as was the specific population of the administrative units (states, provinces, oblasts) surveyed in large countries. The prevalence of resistance to at least one anti-tuberculosis drug among new cases in this new phase of the Global Project ranged from 1. Germany, New Zealand and Peru also showed significantly higher proportions (p < 0. No significant differences were observed in Latvia and Ivanovo Oblast, although high prevalences (9%) were still found in the latest year of surveillance in both settings. Previously treated cases Forty-eight geographical settings provided data on previously treated cases. However, the total number of cases examined in individual settings varied from 2 in Finland to 994 in Poland (median = 64). Resistance to at least one drug ranged from 0% in Finland to 94% in Uruguay (median = 23. Trends from 20 settings showed that there was no statistically significant increase in the prevalence of any drug resistance.

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If the presence of risk factors increases the likelihood of problematic behavior occurring purchase discount confido line, the occurrence of these problem behaviors is generic confido 60 caps visa, in turn buy confido 60 caps low cost, a maintenance factor of the problem situation confido 60caps lowest price. The many factors involved in the genesis and maintenance of drug use, along with the sum of their effect when presented together, oblige researchers to control an enormous number of variables and their interactions. Likewise, from the perspective of methodological rigor, we must bear in mind that, following a criterion of immediacy with drug use, some factors are near, while others are remote. In short, factors interact with each other and form a dynamic network whose result corresponds to a level of risk. The following chart classifies the factors into three basic groups: personal, micro social and macro social, and illustrates the relationships between them. Risk and Protective Factors: Macro social Dimension Far from seeking to do a reductionist detailed reading of the etiology and proposed solutions for the drug phenomenon in our society, this section will explore the characteristics of our society and their influence on the development of problem behaviors and drug use in particular. The relationship of the individual with the closest social environments, such as the micro social spheres of family, school, or group of friends, is the subject of other courses and, therefore, will not be studied in this course. Socio-cultural risk factors, due to their often general character and the difficulty of their methodological control as seen in previous sections, have been the object of less research; thus, they are supported by less evidence. Nevertheless, we agree with Becoña (1999) in asserting that socio-cultural predisposition constitutes one of the most important elements of the whole explanatory process on the initiation and maintenance of drug use. It is a hegemonic model for many young people due to its being the most desired option and at the same time the most accessible one. A model, which has grown in recent decades and is still expanding, around which is woven a dense network of commercial interests that control and foster it. This mercantilist model fosters consumerist free time, in which the majority of leisure options have an economic cost, and if you do not have money, you can stay at home. Certainly, a leisure model based on the alcohol industry, in which the maxim of “sex, drugs and rock and roll” has become an incontestable philosophy and a motto to achieve, is at first glance a clear risk factor for the consumption of alcohol and other drugs. Various authors agree in identifying the interest in going to parties with friends and frequenting bars in nightspot districts as a risk factor (Calafat, 2004; Navarro, 2000). It would be unfair to not recognize the interpersonal functions and benefits that this model of leisure facilitates: it encourages socialization, offers the opportunity to listen to music and dance in common spaces, and facilitates sexual encounters. There are a number of authors who affirm that young people who have experienced sporadic drug use are better socialized (Parker 2003; Shedler and Block, 1990). Under cover of this main model, youth subcultures have emerged in Western society that develop a separate and distinctive aesthetic through fashion styles, musical tastes and the design of unique environments. Likewise, they establish leaders and idols, relate stories and legends, hold their own acts and rites and forge values that define the group. With these components, powerful subcultures are built that give cohesion to groups (urban tribes), strengthen the identity of the group and grant existential meaning to the young people who participate in them. In this way, ecstasy is associated with the dance music of clubbers, cannabis with reggae music, and hallucinogens and entheogens with the hippy culture. Concurrently with drug use, these communities suffer violence, a greater risk of criminal behavior, a lower academic level, and other maladaptive behaviors (Smart et al. The lack of resources and low expectations for improvement increase poverty´s potential risk when said marginality is perceived as a social grievance. This social comparison, in which the compared is situated in the worst position in the face of an opulent society on pompous display, is a source of unrest and tension. Likewise, underdevelopment is a source of unease to the extent that it is perceived as a social grievance. The lack of access to resources translates into a real difficulty to achieving social rights recognized as legitimate, namely: the right to housing, to a professionally rewarding and sufficiently paid job to support a family and enjoy free time, and the right to maintain a standard of living commensurate with the perceived average. The most disadvantaged social classes have inferior access to resources and notice how their efforts produce meager results. Disappointment and a high level of frustration, which can turn into anger and hatred, stem from this situation. This social and psychological tension caused by class differences, predisposes to the search for rapid and accessible "escapes", allowing an ease in tension without addressing its causes. Finally, it should always be remembered that risk factors are not deterministic; and therefore, most of the population living in conditions of social and economic deprivation do not have problems with drugs. Disorganized Community The lack of group cohesion and the absence of community resources capable of organizing the basic needs of the society converts the area into high risk and, thus, into a priority action area. In communities with few or weak social ties, there is an increased risk of drug consumption (Hawkins et al. People living in these communities 11 Analysis of Drug Use Prevention on a Community-wide Scale present greater difficulty at the time of promoting feelings of attachment and feeling part of a community. Some studies have found that the identification with a religious orientation acts as a protective factor. Rather, it may be a mediating variable to develop protective factors related to it, such as the construction of a values structure and the development of community ties. Social Values that Promote the Need to Consume Being and Having The consumer society model, in which being and having fuse into a same meaning, exploits and leverages hedonism and social envy as inexhaustible economic engines. The advertising industry, far from being an information service on the wide range of products and services of our opulent society, and aware of the mobilizing power of the consumption that contains social unrest, has become a Machiavellian needs creation system. Those responsible for advertising and marketing deploy all their seductive skills to maintain in their audience a moderate and constant feeling of dissatisfaction, a sufficiently high and uncomfortable level to arouse the search for relief by means of accessing the solutions proposed by the advertising 12 Daniel Lloret Irles and José Pedro Espada Sánchez industry itself, namely: buy the product that will resolve the previously created need. While the most disadvantaged classes are trapped between revolt and victimism, for not being able to achieve what others get and display through the most sensationalized media. The system is designed so that the act of consuming, purchasing, is the true protagonist, above that of possessing, using and enjoying. Consequently, the entire manufacturing process has been redesigned to limit the useful life of the product, to schedule its obsolescence and plan the purchase of a new one. The aesthetics of industrial design age rapidly, the materials used have been manufactured with components that will lose their qualities in a short time, after-sales service prefers to replace than to repair, and parts and their assembly are often more expensive than buying a new product. The whole system requires that people maintain a purchasing power level capable of fueling industry, which only understands maintaining a steady growth in its turnover. Only individual enrichment will allow acquiring more goods and services than others, and consequently success in a social comparison model based on the wealth standard. The lack of solidarity that is necessarily derived from this philosophy is accepted as a collateral effect. Something that, while not well regarded, one tries to avoid or justify in the interests of an individual opulence without limits. The Power of Impulsivity The acquisition of goods and services on short-term credit installments is on the rise. The “take it today and pay interest free in 12 months” has become the customary Christmas slogan and shopping centers have turned into pilgrimage destinations. Skillfully applying the principles of operant conditioning, short- term positive consequences of buying behavior are promoted on the grounds of delaying costs. Advertising messages are loaded with words that invite immediacy of action (now, already, do not think about it, last day, take it without obligation) and encourage saying yes without allowing time for doubt. Deliberating before a decision, thinking about whether you really need it, assessing whether I really want it or if my desire is transitional or 13 Analysis of Drug Use Prevention on a Community-wide Scale estimating the costs of the acquisition would mean desisting from a large number of purchase attempts. In the realm of the personal, scientific evidence on risk factors has determined the relationship between impulsivity as a personality trait and drug use (Zuckerman, 1983). Likewise, these arguments bear a special parallel with the techniques used in treatments to break drug use habits, in which reducing the compulsive behavior by exercising reflection and anticipation of consequences is a central component of therapy. Accessibility to the Substance Substance accessibility is considered one of the major risk factors and its relationship with consumption has been repeatedly demonstrated through surveys in the general and student populations. The first refers to the actual availability of the drug supply on the market, which can be broken down into two dimensions: price and the frequency and proximity of points of sale. In addition, the measures taken to reduce the availability of alcohol, tobacco and other drugs will be reviewed. Accessibility, in turn, has a personal or subjective version consisting of individual perception of the ease of getting a particular drug. It further depends on the individual´s assessment of his or her ability to find and purchase the drug. As shown in the results of epidemiological studies, accessibility has a directly proportional relationship to substance use.

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Many of the effects of the disease overlap with the more common osteoporosis 60 caps confido with mastercard, but the two diseases are significantly different cheap 60 caps confido free shipping. There are two main causes of osteomalacia: (1) insufficient calcium absorption from the intestine because of lack of dietary calcium or a deficiency of or resistance to the action of vitamin D cheap 60 caps confido overnight delivery; and (2) Phosphate deficiency caused by increased renal losses b buy discount confido online. Case Definition: Osteomalacia is the softening of the bones due to defective bone mineralization secondary to inadequate amounts of available phosphorus and calcium. It may show signs as diffuse body pains, muscle weakness, and fragility of the bones. In the Middle East, a high prevalence of rickets and osteomalacia has been described in Muslim women and their infants, perhaps due to increased clothing coverage of the skin. Clinical diagnosis: Osteomalacia in adults starts insidiously as aches and pains in the lumbar (lower back) region and thighs, spreading later to the arms and ribs. The pain is symmetrical, non-radiating and is accompanied by sensitivity in the involved bones. Proximal muscles are weak, and there is difficulty in climbing up stairs and getting up from a squatting position. However, those physical signs may derive from a previous osteomalacial state, since bones do not regain their original shape after they become deformed. Investigations: Serum Calcium Serum Phosphate Alkaline Phosphatase Serum urea creatinine 24 Hr urinary calcium X rays of the deformed part c. Osteomalacia due to malabsorption may require treatment by injection or daily oral dosing of significant amounts of vitamin D Standard Operating Procedure i. Referral criteria: For evaluation and management of cases not responding to conventional therapy. Introduction: Osteoporosis is a disease of bones that leads to an increased risk of fracture. The form of osteoporosis most common in women after menopause is referred to as primary type 1 or postmenopausal osteoporosis. Primary type 2 osteoporosis or senile osteoporosis occurs after age 75 and is seen in both females and males at a ratio of 2:1. Finally, secondary osteoporosis may arise at any age and affects men and women equally. Amongst the various risk factors for osteoporosis modifiable risk factors can be modified to prevent development of osteoporosis. Referral criteria: For further evaluation and management of cases not responding to conventional therapy. Biochemical markers of bone resorption (increased urinary excretion of C- telopeptides) 4. Efficacy of bisphosphonates in reducing fracture risk in postmenopausal osteoporosis. Consensus development conference: Diagnosis, prophylaxis and treatment of osteoporosis. Biochemical markers of bone resorption (increased urinary excretion of C- telopeptides) 4. The process produces an inflammatory response of the synovium (synovitis) secondary to hyperplasia of synovial cells, excess synovial fluid, and the development of pannus in the synovium. The pathology of the disease process often leads to the destruction of articular cartilage and ankylosis of the joints. Rheumatoid arthritis can also produce diffuse inflammation in the lungs, pericardium, pleura, and sclera, and also nodular lesions, most common in subcutaneous tissue. It can be a disabling and painful condition, which can lead to substantial loss of function and mobility if not adequately treated. Involvement of 1-3 small joints (with or without involvement of large joints) gives 2 points d. Involvement of4-10 small joints (with or without involvement of large joints) gives 3 points e. Involvement of more than 10 joints (with involvement of at least 1 small joint) gives 5 points 2. Onset is most frequent between the ages of 40 and 50, but people of any age can be affected. It is up to three times more common in smokers than non-smokers, particularly in men, heavy smokers, and those who are rheumatoid factor positive. First-degree relatives prevalence rate is 2–3% and disease genetic concordance in monozygotic twins is approximately 15–20%. Clinical diagnosis: Rheumatoid arthritis typically manifests with signs of inflammation, with the affected joints being swollen, warm, painful and stiff, particularly early in the morning on waking or following prolonged inactivity. Increased stiffness early in the morning is often a prominent feature of the disease and typically lasts for more than an hour. Referral criteria: For further evaluation and management of cases not responding to conventional therapy. American College of Rheumatology, 2008 Annual Scientific Meeting, poster presentation. Introduction: Rickets is a softening of bones in children due to deficiency or impaired metabolism of vitamin D, phosphorus or calcium,http://en. Rickets is among the most frequent childhood diseases in many developing countries. The predominant cause is a vitamin D deficiency, but lack of adequate calcium in the diet may also lead to rickets (cases of severe diarrhea and vomiting may be the cause of the deficiency). Although it can occur in adults, the majority of cases occur in children suffering from severe malnutrition b. Sunlight, especially ultraviolet light, lets human skin cells convert Vitamin D from an inactive to active state. Children ages 6 months to 24 months are at highest risk, because their bones are rapidly growing. Mother’s milk gives adequate calcium and vitamin-D so nutritional rickets develops once breast feeding is stopped. Investigations: Alkaline Phosphatase Serum Calcium Serum Phosphorus 157 X rays of the deformed part c. Treatment: The goals of treatment are to relieve symptoms and correct the cause of the condition. Replacing calcium, phosphorus, and vitamin D, Exposure to moderate amounts of sunlight is encouraged. Others are 25 hydroxy – Vit D level 1,25 – dihydroxy- Vit D level 24 hours urinary Ca and Phosphorus levels z. In Patient : as in situation 1 and Recombinant Growth hormone therapy for Hypophosphatemic rickets ii. Prevention of rickets and vitamin D deficiency: new guidelines for vitamin D intake. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Backup attending: A backup attending is available during the day and is called at the discretion of the day attending c. Night attending: Night attending for admission, cross coverage, transport calls/consults, code team response. The role/responsibilities of the surgical fellow will vary depending on their educational goals. One of the pediatric residents should be assigned to “back-up” the subintern on each patient. Write admission orders and admission note (medical patient) or review admission orders and write admission note (surgical patient) 2. Surgical patients do not need notes on the day of transfer (except cardiac surgical patients, who transfer to the cardiology service on the ward/dncc). When gone from unit (post call, clinic, etc), communicate/sign out with resident/s who remain in the unit. Please also notify the attending that you are leaving and summarize any patient care tasks that still need to be done. Write transfer note for medical patients, communicate patient data to receiving resident. For Shriner’s discharges or home discharges, dictate admission (students should not dictate). The above caregivers will distribute patients relatively evenly, within the following guidelines a.

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Look for the penicilli (short buy discount confido on-line, straight arterioles that branch from the central artery and enter the red pulp) cheap confido 60caps with amex. These penicilli branch into capillaries surrounded by accumulations of reticular cells and macrophages and known as "ellipsoids" (or "sheathed capillaries”) buy cheap confido. Germinal center with central artery Between the white pulp and the red pulp is the near the 6 o’clock position marginal zone order confido 60caps without prescription, a vascular region that is devoid of sinuses. The region is the site of immunological activities due to the presence of numerous blood antigens 45 The remainder of the spleen consists of red pulp and is composed of sinusoids (modified blood vessels) and splenic cords (of Billroth). The latter are cellular regions organized as plates of loose lymphatic tissue separating the sinusoids. It is not always possible to distinguish Billroth cords from the sinusoids, as is evident in this preparation where the sinusoids are partially collapsed. The lining cells of these sinusoids are elongated endothelial cells with tapered ends that lie parallel to the long axis of the vessel. In cross sections of sinusoids, therefore, the lining reticular cells are cut transversely and appear as cuboidal blocks arranged loosely in a circle, with intervening gaps. In section, the membrane may be seen as a succession of black points or short lines of silver-impregnated substance. The cardiovascular system is composed of the heart and a continuous system of blood vessels including arteries, arterioles, capillaries, venules, and veins. The innermost layer is the tunica intima, which includes a single layer of cells lining the lumen called the endothelium. There are important histological differences in the composition of these layers within each component of this system, which will be explored later in this lab. Valve Ventricle Atrium #17 Heart, Monkey, Sagittal Section (Mallory-Azan) The epicardium includes a layer of simple squamous epithelium called the mesothelium and underlying supportive connective tissue. The epicardium is the outermost layer surrounding the heart, and is comparable to the tunica adventitia of vessels. In the region of the atrium the epicardium contains fatty connective tissue and vessels of the coronary circulation. The distribution of blue-staining collagen fibers reveals the fascicle organization of the myocardium, which is comparable to the tunica media. In areas where muscle 47 fascicles are longitudinally sectioned, note the intercalated discs which appear as red-staining step-like lines perpendicular to the long axis of the fiber. The endocardium contains an endothelium on the free surface and underlying supportive connective tissue. Conduction continues through the atrioventricular bundle of His and into Purkinje fibers of the ventricles. Purkinje fibers are hypertrophied cardiac muscle fibers that are specialized for conducting an impulse rather than for contraction. They contain one or two nuclei, centrally situated in a pale staining mass of sarcoplasm that is rich in mitochondria and glycogen. Major branches of the bundle of His lie outside the myocardium in the subendocardium, as seen on the right side of this slide. Purkinje fibers traverse the myocardium where the terminal From left to right: muscle fiber, connective tissue, branches merge into muscle fascicles. This purkinje fibers, connective tissue, muscle fiber is seen in favorable longitudinal sections as a point where the Purkinje fibers become smaller, more densely stained, and indistinguishable from fascicles of muscle fibers. Individual muscle fibers are grouped in fascicles that are seen in both cross and longitudinal section on this slide. The fascicles are bounded by connective tissue containing blood vessels of the coronary circulation and nerve fibers. Remember that red blood cells are often visible in the lumen of blood vessels, however they will not be present in every lumen due to preparation of the slides. Larger vessels have a common structural plan in that they are composed of three concentric coats or tunics. This consists of the endothelial lining and its basement membrane, and a delicate layer of loose subendothelial connective tissue. The nuclei of the simple squamous epithelial cells of the endothelium protrude into the lumen of the vessel. In arteries and arterioles, an internal elastic membrane delimits the outer margin of the tunica intima. This coat consists predominantly of fibroelastic connective tissue whose fibers generally occur in a longitudinal array. In larger muscular arteries, there is frequently an external elastic membrane separating the tunica adventitia from the tunica media. Arteries have an internal elastic membrane (although it is less distinctive in large elastic arteries). It is predominantly muscular in arterioles and most arteries, but is predominantly elastic in the largest arteries (the so-called elastic arteries) such as the aorta and the common carotid. A useful generalization is that arteries have a relatively thick wall with a small lumen, whereas veins have a relatively thin wall and a broad lumen. Arterioles and small arteries exhibit a distinctive Artery top, vein bottom arrangement of endothelial cells and smooth muscle fibers in their walls. The endothelial cells are oriented longitudinally, whereas the smooth muscle fibers in the adjacent tunica media are wrapped around these vessels in a circular fashion. The Aorta The sections on these slides are stained to demonstrate elastin, collagen and the cellular organization of the aorta. The aorta is an elastic artery which has a relatively thick tunica intima bounded by endothelium and the internal elastic membrane. In the tunica intima smooth muscle cells run parallel to the long axis of the aorta while in the tunica media smooth muscle is spirally arranged. Within the tunica media the distribution of elastin in the elastic laminae is revealed as red-staining or black-staining material by the elastin stain. Elastin is not stained in the Masson preparations, but can still be seen as clear, refractile material surrounded by blue-staining collagen fibers. Both elastin and collagen are produced by smooth muscle cells, which are the only cell type within the tunica media. Tunica adventitia tunica media Tunica intima #16 Aorta, Rhesus monkey, Cross Section #20 Aorta, Cross Section (Elastin Stain) In slides #16 and #20 the blood vessels supply the aorta, the vasa vasorum, should be identified in the tunica adventitia. The major component of the wall of the artery is spirally arranged smooth muscle (therefore seen here in longitudinal section). Note that the nuclei are elongated and that due to contraction of the vessel wall, some of them appear corkscrew shaped. The nuclei are relatively euchromatic (as compared to those of fibroblasts in the adventitia of the vessel). The smooth muscle cells, in addition to contracting to control the diameter of the vessel, also produce collagen and elastic fiber components of the muscular part of the vessel wall. This laboratory exercise serves both as an introduction to the skin, the largest organ of the body, and as a review of the major tissues. As you study the slides of the skin, identify examples of epithelium, connective tissue, muscle and nerve. All skin is made up of three layers: Epidermis- stratified squamous keratinizing epithelium Dermis – a superficial papilllary layer of loose connective tissue, underlain by a reticular layer of dense fibrous irregularly arranged connective tissue Hypodermis – deepest layer of skin, also called subcutaneous tissue, made up of loose connective tissue and adipose tissue #4 Skin, thick skin, volar surface H&E Epidermis: The stratified squamous keratinizing epithelium of the epidermis is made up primarily of keratinocytes. The layers of the epidermis from basement membrane to skin surface include: Stratum basale: Cells of all the layers are generated from the keratinocytes in this layer. The keratinocytes in this and the overlying layers contain melanin granules that have been transferred to them by melanocytes. Because the cells pull apart during preparation, the attachment sites give the cells a spiny appearance. Stratum granulosum: The cells of this layer are recognizable by their basophilic keratohyalin granules containing filaggrin and other proteins binding tonofibrils. Stratum corneum: The superficial keratinized layer is the stratum corneum, which protects the skin against friction, infection, and water loss. They are coiled tubular glands with an acidophilic margin, which corresponds to the layer of myoepithelium.

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Heparinised saline is no longer routinely used  The reference point is usually at the level of the heart where the transducer is zeroed order confido 60caps without prescription. Other veins that may be used are the arm veins (basilic discount 60 caps confido, cephalic) cheap 60caps confido with amex, external jugular and femoral veins cheap confido generic. The fluid challenge is performed in 4 steps: o Select the type of fluid: usually normal saline or a colloid o Infuse rapidly. Rate of infusion: 500ml of crystalloid or 200 ml of colloid over 20-30 minutes o Target the Desired therapeutic response: the parameters are set empirically by the physician. This brought the catheter out of the domain of radiologists and at the bedside of the patients in intensive care. An SvO2 below 65% implies low oxygen delivery, while a value below 60% indicates that there is a serious risk of tissue hypoxia if corrective measures are not taken. In some disease states, cells in some tissues are unable to assimilate and/or process the needed oxygen. Indications  Management of complicated myocardial infarction • Hypovolemia vs cardiogenic shock • Severe left ventricular failure  Assessment of type of shock  Septic shock  Assessment of therapy • Afterload reduction • Vasopressors • Beta blockers • Intra-aortic balloon counterpulsation  Assessment of fluid requirement in critically ill patients • Hemorrhage • Sepsis • Acute renal failure • Burns  Management of postoperative open heart surgical patients Methods of monitoring cardiac output  Thermodilution (intermittent or continuous) using the pulmonary artery catheter has been the classical method of cardiac output monitoring. A central venous catheter, special thermistor tipped femoral artery catheter and monitor are required. The additional advantages are the values of extravascular lung water, global end-diastolic volume and the stroke volume variation (a dynamic measure of preload). They are not reliable in patients ventilated with low tidal volume and in patients with increased intraabdominal pressure  In these cases Passive leg raising is an alternative choice. Line 70 0 70 Saline, syringes 400 200 200 Total Initial Set up 11,470 12750 9770 Cost (Does not Add Presep include capital cost of continuous hemodynamic ScvO2 catheter monitors) 8000 Total: 17700 Daily monitoring cost 4500-5000 4500-5500 3500-4000 (based on an average of 3 days monitoring, 6000-7000 does not include including professional fees) Presep Further reading: 1. Minimally invasive hemodynamic monitoring for the intensivist: Current and emerging technology Crit Care Med 2002; 30:2338 –2345 6. Equipment review: New techniques for cardiac output measurement – oesophageal Doppler, Fick principle using carbon dioxide, and pulse contour analysis. Hemodynamic monitoring in shock and implications for management International Consensus Conference, Paris, France, 27–28 April 2006. It should be suspected anytime there is hypotension accompanied by an elevated central venous pressure (or neck vein distension), which is not otherwise explained by acute myocardial infarction, tension pneumothorax, pericardial tamponade, or a new arrhythmia. The concern about radiation is overcome by the hazard of missing a potentially fatal diagnosis or exposing the mother and fetus to unnecessary anticoagulant treatment. Despite the advances in the treatment and the understanding of the pathophysiology of sepsis, the mortality has remained unforgivably high. The site of infection is difficult to estimate and even among those patients where the site is strongly suspected, cultures might be negative or of questionable significance. Though a positive blood culture would be diagnostic, the rate of positivity is only 30 to 50 % percent. It is easy to confuse the diagnosis of sepsis with conditions that simulate it such as pancreatitis or anaphylactic reactions or drug fever. Early identification and prompt treatment is the key to reduce mortality a) Case definition: Till 2001 there was no clear definition of sepsis. Although making the distinction of the above conditions from true sepsis becomes difficult, using different biomarkers and imaging studies might be helpful in making the diagnosis. Close monitoring and optimising the patient physiological variables will give us time to identify the exact insult. Organ dysfunction variables:  Respiratory –Decreased oxygen saturation  Renal – Acute oliguria urine output <0. Rapid diagnosis, expeditious treatment multidisciplinary approaches are critical and necessary in the treatment of sepsis. Diagnosis 1) Cultures with gram stain- Obtain appropriate cultures before starting antibiotics provided this does not significantly delay antimicrobial administration. Begin intravenous antibiotics early within the first hour of recognizing Severe sepsis or septic shock. Early and appropriate antibiotic therapy and control of the source of infection arethe major therapies shown to improve survival in sepsis. Source of infection should be established as rapidly as possible and start measures to control the source within the first 6 hours of presentation as soon as the initial resuscitation is done e. Source control measures must be directed at achieving maximal efficacy with minimal physiological upset. Epinephrine, phenylephrine, or vasopressin should not be used as the initial vasopressor in septic shock 3. In case of myocardial dysfunction as evidenced by increased cardiac filling pressures and decreased cardiac output dobutamine can be used. Do not use steroids to treat sepsis in the absence of shock and wean it once vasopressors are no longer required 3. But its use for correcting laboratory clotting abnormalities is contraindicated unless an invasive procedure is planned. Lung protective ventilation strategy using low tidal volume ventilation reduces ventilator- induced lung injury like volutrauma, barotrauma, atelectrauma and biotrauma. This is the only ventilator manipulation that has been shown definitively to reduce injury and absolute mortality reduction of 9%. Do not use bicarbonate therapy to improve hemodynamics or reducing vasopressor requirements with lactic acidemia and pH < 7. Use a mechanical prophylactic device, such as compression stockings or an intermittent compression device, when heparin is contraindicated. Serum procalcitonin measurement as diagnostic and prognostic marker in febrile adult patients presenting to the emergency department. Introduction Community acquired pneumonia affects 2 to 3 million patients per year and carries high mortality of around 30% in severe cases. Case Definition Patient usually presents with a constellation of respiratory symptoms like cough, purulent sputum and sometimes pleuritic pain associated with constitutional symptoms like fever, lack of appetite and myalgia. Presentation: Preceding airway symptoms, myalgias, fever without chills, headache, unproductive cough. Chest x- ray shows- diffuse, patchy or ground glass shadows Assessment of Severity This is a crucial step as it will help in identifying patient who are prone to get complication and should be admitted in intensive care unit. D Dimer Treatment: Initial Choice of Antibiotic A detailed history should be taken to identify patients who are at high risk of drug resistant infection. Duration of Antibiotic therapy: Duration of antibiotic should be individualized based on clinical response,type of organismbiomarker response, development of complications and comorbidities. Prolonged antibiotics upto two 100 weeks should be considered inselected cases like slow responders, pseudomonas and staph infection,lung abscess , empyema,metastatic infection. Identification of Non-Responders With appropriate antibiotic therapy some improvement in patients clinical course should beseen within 48 to 72 hours. Atypical organisms – Tuberculosis, strongyloidosis, meliodosis , H1N1 influenza etc 3 Complicated pneumonia- Lung abscess, empyema. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Canadian guidelines for the initial management of community-acquired pneumonia: An evidence-based update by the Canadian Infectious Diseases Society and the Canadian Thoracic Society. Introduction Community acquired pneumonia affects 2 to 3 million patients per year and carries high mortality of around 30% in severe cases. Case Definition Patient usually presents with a constellation of respiratory symptoms like cough, purulent sputum and sometimes pleuritic pain associated with constitutional symptoms like fever, lack of appetite and myalgia. Presentation: Preceding airway symptoms, myalgias, fever without chills, headache, unproductive cough. Chest x- ray shows- diffuse, patchy or ground glass shadows Assessment of Severity This is a crucial step as it will help in identifying patient who are prone to get complication and should be admitted in intensive care unit. D Dimer Treatment: Initial Choice of Antibiotic A detailed history should be taken to identify patients who are at high risk of drug resistant infection. Duration of Antibiotic therapy: Duration of antibiotic should be individualized based on clinical response,type of organismbiomarker response, development of complications and comorbidities. Prolonged antibiotics upto two 104 weeks should be considered inselected cases like slow responders, pseudomonas and staph infection,lung abscess , empyema,metastatic infection.

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