By X. Stejnar. Missouri State University.

Decontamination The recommended decontamination solution is hypochlorite in large amounts order generic bupropion pills, though large quantities of soap and water are more practically employed buy cheap bupropion 150 mg on-line. Treatment Early treatment with nonsteroidal anti-inflammatory drugs has been shown to be beneficial against the cutaneous injury caused by mustard bupropion 150mg amex. Nerve agents produce a clinical syndrome similar to that of organophosphate insecticide poisoning but order bupropion no prescription, with far greater toxicity. The pupillary constriction is often associated with intense pain (which may consequently induce nausea and vomiting). Miosis results in dim or blurred vision; the conjunctiva often become injected and lacrimation occurs. Exposure results in increased salivary gland secretion as well as other gastrointestinal glandular secretions. Skeletal muscles initially develop fasciculations and twitching, but they become weak, fatigued, and eventually flaccid. Respiratory effects include rhinorrhea, bronchorrhea and bronchoconstriction depending upon the severity of exposure. High dose exposure may result in loss of consciousness, seizure activity and central apnea. High- dose vapor exposure may present as seizures or loss of consciousness in less than one minute, whereas low-dose skin contact may not present as long as 18 hours later when the victim appears with gastrointestinal complaints. Measurement of red cell cholinesterase (ChE) inhibition is more sensitive than measurement of plasma ChE activity in the setting of nerve agent exposure. However, although helpful in confirming exposure, results are not immediately available as few clinical laboratories can perform these tests and levels do not generally correlate with physical findings. Decontamination Decontamination is the key element in mitigating the effects of nerve agent poisoning on patients and health care workers. All suspected casualties should be decontaminated prior to entering a medical facility. However, if exposed to a liquid agent, even asymptomatic victims should be observed for 18 hours. When triaging multiple casualties, patients recovering from exposure and treatment in the field can normally be placed into a delayed category. Ambulatory patients and those with normal vital signs can be categorized as minimal. Triaging of patients who are apneic, pulseless, or without a blood pressure will depend on available resources. Ventilatory support is complicated by increased secretions and airway resistance (50 to 70 cm H2O). Treatment Treatment of nerve agent casualties, like other poisons, requires appropriate administration of antidotes. Atropine is an anti-cholinergic and serves as the primary antidote for nerve agent exposure, with its greatest effect at muscarinic sites. The recommended atropine dose is two-milligrams every three to five minutes, titrated to secretions, dyspnea, retching or vomiting. Nebulized ipratropium bromide may be of help in managing secretions and bronchospasm. Fasciculations can persist after restoration of consciousness, spontaneous ventilation, and even ambulation. This oxime is effective only at nicotinic sites thereby, improving muscle strength but not secretions. For seizures, Diazepam is the anticonvulsant of choice, based primarily on its historical use and demonstrated effectiveness, but other benzodiazepams may be substituted. Ketamine has also been used as an anticonvulsant because of its neuroprotective and antiepileptic activities15. More aggressive therapy may include the use of hemodiafiltration followed by hemoperfusion, which was successfully employed in the management of one victim of the Tokyo sarin attack. The diversity of the effects of sulfur mustard gas inhalation on respiratory system 10 years after a single, heavy exposure. The protective effects of zinc chloride and desferrioxamine on skin exposed to nitrogen mustard. The role of bronchoscopy in pulmonary complications due to mustard gas inhalation. Effects of sarin on the nervous system in rescue team staff members and police officers 3 years after the Tokyo subway sarin attack. Anticonvulsant treatment of nerve agent seizures: anticholinergics versus diazepam in soman- intoxicated guinea pigs. Review of oximes in the antidotal treatment of poisoning by organophosphorus nerve agents. Neuroprotective and antiepileptic activities of ketamine in nerve agent poisoning. The first is worldwide pandemic infection, itself the cause of a healthcare disaster. And the third is bio-attacks such as the inhalational anthrax exposures that occurred in the United States in 2001. As of June 2010, worldwide more than 214 countries and overseas territories or communities have reported laboratory confirmed cases of pandemic influenza H1N1 2009, including over 18,209 deaths. Far greater numbers have been infected as many countries, including the United States and Canada, have not been counting milder cases and only using laboratory testing to confirm more severe cases. The United States and Canada are both reporting rates of influenza-like illness well above seasonal baseline rates. Because, most individuals less than 65 do not have natural immunity to H1N1, disease has been more severe in the young than in the elderly. For example, in the United States during 2009, 32% of those hospitalized due to H1N1 influenza have had pre-existing asthma. Those with immunologic disorders or who have household members with immunologic disorders should only receive the flu-shot which contains inactivated vaccine (killed virus) and should not receive the flu-nasal-spray which contains live weakened virus. The potential still remains for avian influenza A subtype H5N1 developing the capacity for widespread, efficient, and sustainable human-to-human contagion. The first recognized human outbreak of avian influenza H5N1 occurred between May and December 1997 in Hong Kong3 infecting 18 persons, mostly children and young adults (half less than 19 years old and only two older than 50 years). Influenza-related pneumonia can be viral or a secondary bacterial or mixed infection. The predominant organisms responsible for secondary bacterial pneumonia vary with Hemophilus influenza, beta-hemolytic streptococci and Streptococcus pneumonia during the 1918 influenza pandemic; Staphyloccus aureus during the 1957 pandemic; and S pneumonia, Staphylococcus aureus (26%) and Hemophilus influenza during the 1968 pandemic. The mortality rate in mixed viral bacterial pneumonia is as high as for primary viral pneumonia (>40%)7,6,9,10. The current recommendation during a pandemic flu alert is to treat with an appropriate antiviral medication early on in the presentation of flu-like symptoms and fever (< 2 days). Corpses do not need to be buried or burned rapidly and instead victims should be identified and dealt with consistent with legal, cultural and religious beliefs thereby, diminishing psychological stress for the large number of potentially-affected survivors. Malnutrition is associated with higher mortality rates from diarrheal illness, measles, malaria, and acute respiratory illness. The interdependency between malnutrition and infectious disease on mortality rates is most evident in vulnerable populations such as children and patients with pre-existing co-morbidity. During a disaster, the majority of all infectious disease mortality is related to diarrheal disease (not the subject of this review), respiratory infections18 and measles. Clinical field data should be routinely collected, shared, collated, and disseminated at regular meetings among various relief organizations to inform and respond to potential outbreaks. Surveillance case recognition should be based on easily identified clinical scenarios. Immediately after Hurricane Andrew hit Florida in 1992, a surveillance system was initiated utilizing data from over 40 sites. Surveillance focused on five presenting complaints (diarrhea, cough, rash, animal bite and other infectious symptoms ) that were targeted for rapid intervention with the result that morbidity and proportional mortality was not increased for diarrhea or cough. Poor hygiene, overcrowding and malnutrition add to the risk for endemic infections becoming epidemic. Tuberculosis22 can also occur in refugee camps in the developing world but, mortality is typically low. Measles, prior to mass immunization programs, was the infection most associated with high mortality rates.

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In both groups purchase bupropion with a visa, oral antibiotics (neomycin lg and metronidazole 400mg 8 hourly) were given two days before operation generic 150 mg bupropion free shipping. Prophylactic parenteral antibiotics (third generation cephalosporin 1g and metronidazole 500mg) were given before the induction of anaesthesia and continued for 48 hours buy bupropion 150mg online. There were 8 male and 7 female patients in group A and 6 male and 9 female patients in group B order bupropion with american express. Preoperative diagnoses were obtained by clinical radiological investigations and by colonoscopy. Those intestinal tuberculosis showed improvement in appetite, weight gain and sense of well being. Although there is no difference in mortality and morbidity between the two groups statistically, with such a small sample, it is rather not strong enough to conclude that right hemicolectomy without mechanical bowel preparation is comparable in outcome to the traditional method. The aim of the study is to evaluate the efficacy and safety of combined epidural technique by comparing with the conventional narcotic based general anaesthesia. Sixty patients to be operated for lower abdominal operations were randomly allocated into two groups. Thirty patients from the control group were operated under narcotic based general anaesthesia and patients from the study group were operated under combined epidural and general anaesthesia technique. Post-operative recovery status and duration of post-operative residual analgesia were also recorded. The rises in blood pressure during operation were less than 25% of the baseline value and clinically not seriously important. The rises in systolic pressure, diastolic pressure arid mean arterial pressure are statistically significant by comparing with the data of the study group. But these data show that conventional narcotic base general anaesthesia technique was less efficient to obtund the sympathoadrenal response to surgery and anaesthetic procedure. In contrast, the rises in systolic blood pressure, diastolic blood pressure and mean arterial pressure were less significant in study group than in control group. There was some fall in systolic bloc pressure, diastolic blood pressure and mean arterial pressure in early period of operation. But the fall in blood pressure was less than 25% of the base line values and symptoms attributed to hypotension such as nausea, vomiting and restlessness were not found. There was statistically significant higher differences in control group than in study group (p<0. Means of the pre-operative blood glucose level of the patients in control group and study group were 88. After operation, higher blood glucose was found in control group than in study group. Thirty minutes after reversing from effect of muscle relaxant, all the patients from study group got fitness for discharge from recovery area. At that time 10 of the patients from control group are still less than recovery score 8. Delay recovery may be related to the effect of narcotic which was used in control group. It may be due to stable blood pressure, effective analgesia (reflex suppression) and avoidance of narcotic drugs in study group. In conclusion, newer technique combined epidural and general anaesthesia may be efficient enough to fulfill the required condition during operation and gap between the optimal condition and present condition may be narrowed. The sympathetic supply of the stomach was by the greater splanchnic nerves through the coeliac plexus. The roots of the greater splanchnic nerves arose from as high as 4th thoracic ganglion and as low as 10th thoracic ganglion: even variable origins in each side of the same specimen were observed. In the majority of cases, the segmental origin of the greater spanchnic nerve was found to come th th from the 6 to 9 thoracic ganglia (78% on the right side and 84% on the left side). In most of the cases, the parasympathetic nerves were seen to arise from a single anterior vagus and, a single posterior vagus (73. However, in 8 cases, two anterior vagal trunks and one posterior vagal trunk were seen (17. The histological examination of the distribution and the mode of termination of the gastric nerves were determined in the stomachs of 15 human adults, 3 human fetuses, 8 albino rat, and 4 specimens from operative biopsy tissue by using various neurohistological and histochemical techniques. Nerve plexuses and ganglia were observed in the submucosa, muscular, and serosa layers of the stomach. Free as well as encapsulated endings were observed in the wall of the stomach of human and albino-rats. The type of nerve endings were free and free but organized endings such as loop-like endings. Pharmacological experiments were done in the stomachs of 2 albino-rats to prove the sympathetic and parasympathetic activities. Sympatho- mimetic agents were seen to evoke inhibitory responses where parasym-pathomimetic agents were found to evoke excitatory responses. Neurohistological and histochemical studies were done on the specimens from fifteen human adults, three human fetuses, eight albino-rats, and four specimens from human operative biopsy tissue. All parts of the stomach were supplied by the gastric branches of the coeliac plexus formed by both th th vagi and greater splanchnic nerves mainly from 6 to 9 thoracic ganglia. Neurohisto- chemically nerve plexuses and ganglia were observed in the submucosa, muscular, and serosa layers of the stomach. Intraepithelial free nerve endings, free but organized nerve endings such as loop-like endings and encapsulated endings such as Meissner s corpuscle and small bulbous corpuscles were 190 Bibliography of Research Findings on Gastrointestinal Diseases in Myanmar seen. Histochemicaly, acetylcholinesterase - positive ganglia, varicose nerve fibres and formaldehyde fluorescent nerve plexus were observed. Pharmacological experiments with sympathomimetic agents, sympatholytic agents, parasympathomimetic agents, and parasym- patholytic agents were done in the stomachs of two albino-rats to prove the sympathetic and parasympathetic activities. The review also outlines the rational approach to promotion of growth of Myanmar children. Studies conducted in Myanmar have shown that rice malabsorption is common in children, and may occur in up to two thirds of the population. It is possible that Helicobacter pylori infection frequently acquired during childhhod in developing countries has an impact on small bowel function. The precise mechanism is unknown but it has been proposed that it relates to the impact of infection on acid secretion, resulting in hypochlorhydria which may open the gate to enteric infections, small bowel bacterial overgrowth, and associated carbohydrate malabsorption. Elucidation of these mechanisms would allow a rational approach to promotion of growth of Myanmar children. An increase in the number of siblings was also found to be a high risk factor for H. Density of living, drinking water source, and type of latrine were not significantly associated with H. The findings indicated that intrafamilial transmission could play an important role in the high prevalence of H. Before implementation of clinical use of such a serological test requires validations for local use. Again growing popularity of "test- and-treat" policy requires evaluation of usefulness of such serological test-performance among under and over forty-five years age groups. The objectives were: a) to compare the gastric acid secretion together with urine acid output between malnourished and well-nourished children, b) to determine the relationship between the gastric acid secretion and urine acid out put. The study was carried out during June to December 2000 at the Yangon Children Hospital. Gastric acid secretion and urine acid output level before and after coffee stimulation in 40 malnourished and 20 well-nourished children. It was found that there was significantly decreased volume of stimulated gastric acid secretion within first hour (17. However, there was no significant quantitative relationship between gastric acid secretion and urine acid output in both malnourished and well-nourished children. Malnourished children were unable to respond appropriate to a stimulus for gastric acid production, poor response was markedly observed in children with kwashiorkor and lesser extent in marasmic-kwashiorkor children. All these patients underwent semi-urgent haemorrhoidectomy (Standard Ligation and Excision). During hospital stay, early post-operative complication were elected and compared with other series. On each visit of the follow-up, late post- operative complications was explored and the results were also compared and discussed with the other series. Study was done regarding the incidence, clinical presentation, pathological staging and type of operation and postoperative complication.

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Sources of stress for residents and recom- temic aspect of the hidden curriculum effective 150mg bupropion, and this also infuences mendations for programs to assist them buy bupropion 150mg free shipping. The infuence of personal and environmental factors on professionalism in medical edu- Strategies to promote a healthy working and learning environ- cation buy 150 mg bupropion with amex. Some faculties of medicine have done just this by developing innovative 150 mg bupropion otc, bottom-up, relational-centred care and teaching models that are transforming the environment in which all physicians and health care teams function. They emphasize mentorship, communication and compassion, and increased face time between residents and faculty in order to promote healthy role modelling and reduce trainee distress (Mareiniss 2005, and Cottingham et al 2008). In addition, postgraduate Case medical education offces have taken steps to develop health A third-year resident who provides on-call services at a and safety policies specifcally for their trainees, presumably to mid-sized community hospital is called to the emergency delineate appropriate local responses to identifed inadequacies room to consult on a patient. Environmental health risks include accidents confrmed the resident s confdence in their expanding and exposures to hazardous agents such as chemicals and knowledge and skills. Occupational risks include exposures to blood and other bodily fuids and to respiratory pathogens. Personal safety The triage nurse directs the resident to the room where the risks include exposure to violence perpetrated by patients or patient is waiting and closes the door behind her. In addition, programs traditionally offer orientation in working safely with hazardous materials and in communicable Many minutes later, when the resident manages to calm disease precautions and protocols. Individual programs that the patient to the point where the resident can make a safe involve specifc and frequent environmental exposures (e. Although they discuss the appropriate man- training to minimize risks of special relevance to these residents. These include but are not limited to exposures A further challenge of preparing residents to protect their own to hazardous materials and communicable pathogens, aggres- safety is that some risks are not immediately apparent, or may sive and violent patients, and repetitive strain injuries. Many of same time, elements of postgraduate training put residents at these are related to the number of hours spent in the health care additional risk of which trainees and their programs or institu- setting, very often at the least secure times. On-call residents tions may not be suffciently aware and so may not adequately and their nursing colleagues are frequently in the position of address. This, combined with their relative inexperience in identifying when a situation is getting out of hand, can increase their risk of assault by a patient. Like many mid-level residents, this resident is trying to bal- ance the confdence gained from working more indepen- These incidents can be extremely stressful to residents, who dently with the limitations of their experience. Residents may feel inadequately trained to deal with them on their own may not consider that they will be placed in situations that and may be unfamiliar with reporting protocols. Accreditation could cause them harm, and therefore rely on hospital poli- visits routinely examine the physical layout where residents cies and procedures to ensure their safety needs are met. In train to ensure they are properly equipped, for example by this case, such procedures were fawed. The resident was means of alarms and proximity to support staff, to prevent focused on making a proper diagnosis and management violent assaults by patients. However, these assessments might plan, rather than on assessing the risk of the situation. The not examine other less controllable settings were residents resident began the patient encounter without considering see patients, such as community clinics and patients homes. Additionally, the resident may not have had the skills Where specifc education and training programs exist to and training to calm an increasingly agitated patient, and manage workplace violence, residents and students are more did not have a supervisor present to review the situation likely to report incidents and get the support they need. Intimidation and harassment by faculty, staff and colleagues can present safety risks that An additional risk for this resident was inherent in the residents are, generally speaking, reluctant to disclose. Protecting Residents are aware that certain risks are associated with the the safety of medical students and residents [editorial]. Trainee miss out on a great learning opportunity, or fear of repercus- safety in psychiatric units and facilities: The position of the sion if they appear too hesitant or dependant, residents may Canadian Psychiatric Association. A pilot survey that residents are trained in risk assessment and in policies and of patient-initiated assaults on medical students during clinical procedures to follow when breaches occur. In different parts of the world, including our own, health and Case education systems have struggled with the issue of resident One of the nurses has made a complaint about a senior work hours. The Europe and the United States, considerable attention has been resident requests a meeting with the program director, paid to resident work hours on a larger scale; this has had the who notes they look exhausted. The resident indicates that beneft of bringing increased awareness of and attention to all the residents are exhausted. The resident explains that patient safety and outcome management from the perspective they are working maximum call; a number of residents of health professional fatigue. Because training systems dents primarily teaching each other topics as part of their and trainees alike can ignore the boundaries set by a collective preparation for certifcation examination); and a bus strike agreement, the challenge is to create a culture of dual account- has contributed to lengthy commutes. Particularly areas of they are doing what they can to demonstrate their abilities workplace safety such as fatigue management, collective agree- as a resident but admits to being exhausted. Embedding safety as a core work- place and educational value can have a positive and sustainable Introduction infuence if it is genuine, explicit and promoted. Handover is a particularly vulner- On-call shifts of 24 consecutive hours or more are associated able time for errors in patient care. Written and oral handover with practices that are interdisciplinary and team-oriented have been a sevenfold increase in the incidence of preventable shown to reduce such errors. In addition, handover is increas- medical errors, ingly being recognized as a skill that requires formal training, a 35 per cent increase in the risk of committing a serious evaluation and revision. Work-hour double the risk of having a motor vehicle accident reductions in the United States and Europe have been associ- during the post-call commute, and ated with unusual and innovative practices. Using shift-work performance impairment similar to that induced by a models familiar in the world of emergency medicine but less blood alcohol level of 0. Increasingly, programs are developing poli- human resource issues that, she readily admits, are more cies to minimize the use of pagers. The pro- gram director also begins to shift educational sessions to Invest in other human resources. By optimizing the involve- models that allow for ready digitization and remote access ment of physician assistants, nurse practitioners, phlebotomists, by residents. These professionals can help ensure medical errors, adverse events, and attentional failures. Extended work shifts and the risk of motor indeed, all hospital professionals) are particularly vulnerable vehicle crashes among interns. Many other practical and comprehensive solutions to the bur- den of excessive work hours during residency, as described by Ulmer and colleagues can be considered in a Canadian context. As we continue to improve patient safety, quality outcomes and excellence in residency training and education, we will need to be open to more systemic interventions targeting fatigue management. First and foremost, they expect that their physicians may confict with those of their training pro- physician will be competent. They ex- Case pect to be trusted because it is diffcult to carry out the healing A fnal-year surgical resident has been the lead doctor function in the absence of trust. They wish to be given suf- treating a 62-year-old widow with carcinoma of the colon. They The resident carried out the surgical procedure with the expect patients to accept some responsibility for their own assistance of the attending surgeon. Canadian physicians want their health care system to be the resident and regards the resident as her surgeon. The equitable, adequately funded and staffed, and to afford reason- patient is aware of the diagnosis and understands that able professional freedom. She lives alone there is a balance between the practice of medicine, family and and wants her family to participate in the discussion about other interests. Finally, they expect reasonable rewards, both treatment options before her discharge. In Canada, the broad outline of these has tickets to a hockey game with their son as a birthday expectations is documented in a contract. For Introduction example, it is inconceivable that a resident would leave a care Professionalism has been described as the basis of medicine s setting at the end of a shift when to do so would put a patient s social contract with society. The most signifcant tension that This bargain with society leads to tangible expectations on may arise stems from a confict between altruism a sense of the part of patients and society on one side and on the part of obligation to put patients needs above one s own and the physicians and the profession on the other. In contem- all of the obligations expected of physicians in a complex and porary Canada, this tension is exacerbated by a real shortage of frequently underfunded and understaffed health care system physicians and other health care professionals, which has led often places impossible demands on individual physicians. No one likes to see others go without access to a physician or endure long waits for treatment.

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