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By N. Sanford. Sarah Lawrence College. 2019.

Two metal pipes may be permanently joined by one of two methods: Gas-tight connections within the machine 1 order eldepryl 5 mg overnight delivery. One pipe may have a slightly larger diameter than The various components within the anaesthetic machine the other so that they overlap (Fig purchase eldepryl online now. Where the diameters are similar order 5mg eldepryl with mastercard, both ends are almost entirely made of high-density nylon buy eldepryl 5mg otc, previously inserted into a sleeve of metal (Fig. After Whilst there is no standard for the design of gas piping making such a joint it is important that all traces of fux within the machine, with the advent of nylon tubing, are removed. Flux is a material applied to the surfaces to manufacturers tend to use pipes of differing diameters be bonded, allowing the molten fller to spread more Securing nut Pipe A A Molten filler C Pipe B Securing nut Washer Pipe A Pipe B B Molten filler D Tapered thread Figure 4. A leak from the cyclopropane tube in the traditional form of fowmeter block would result in back-pressure from the nitrous oxide, causing oxygen to escape through the leak. A rearrangement whereby the oxygen is the last gas to enter the mixed gas fow and nitrous oxide rather than oxygen would be expelled through a leak. Values must be accurate to within 10% of the nitrous oxide fow control valves to be adjacent, as they indicated fow (at fow rates between 10% of full are linked by a sprocket and chain or cogwheel. Traditionally, this was valve spindle without rotation (at a fow rate 25% unfortunately arranged in such a way that if there were a of the maximum indicated fow), the maximum fow leak in, say, the central tube, oxygen would be lost rather change must not be greater than 10% or 10 ml min–1, than nitrous oxide. Each fow control valve must be permanently and advent of hypoxic guard interlinks) led to patients receiv- legibly marked, indicating the gas it controls (using ing a hypoxic mixture because anaesthetists have not been the name or chemical symbol). As well as conforming to (4), the oxygen fow The practice of removing carbon dioxide cylinders (and control knob (Fig. Oxygen can be lost must project at least 2 mm beyond the knobs via a retrograde leak through a carbon dioxide (or cyclo- controlling other gasses at all fow rates. Its diameter propane) fowmeter, even when intact, if the corres- must also be greater than the maximum diameter of ponding needle valves are inadvertently left open. They were meter on the extreme left, the nitrous oxide on the extreme not spring loaded because they were designed to work right and those for compressed air and carbon dioxide against high back pressures rather than the relatively low (where ftted) in between these. All empty cylinder yokes for air, carbon Anti-hypoxia devices dioxide and cyclopropane (where these still exist) should Anaesthesia machines in use now must either not be be ftted with blanking plugs (Fig. Of these approaches Recent increased interest in low-fow anaesthesia systems it has proven ultimately safer and simpler to design a has created a demand for fowmeters that can more accu- –1 system whereby it is physically impossible to set the rately measure fows below 1 l min. This is achieved by nitrous oxide and oxygen fow rates to give hypoxic mix- the use of two fowmeter tubes for the same gas. Some approaches taken by manufacturers are dis- is a long thin tube accurate for fows from 0 to –1 cussed below. These ‘cascade’ fowmeter tubes for each gas are The ‘Link 25’ system (Ohmeda) (Fig. At fows over 1 l min–1, the bobbin in the low-fow oxide spindle that relays its movement to a larger cog on tube is no longer easily visible. The oxygen cog moves along a static, hollow worm gear, through which Carbon dioxide fowmeters the oxygen fowmeter spindle passes. As the nitrous oxide The provision of carbon dioxide on anaesthetic machines fowmeter control is turned counter-clockwise (increasing is somewhat controversial, as several deaths have occurred the nitrous oxide fow), the chain link moves this larger owing to the inadvertent and excessive use of the gas. Typi- cog nearer to the oxygen fowmeter control so that, when cally, in these accidents, the fowmeter valve had been left a 25% oxygen mixture is reached, it locks on to the oxygen fully open either during a check procedure or at the end control knob and moves it synchronously with any further of a previous case, and the bobbin was not readily noticed increase in nitrous oxide fow. The next patient then of course be independently opened further, but cannot be received in excess of 21 min–1 of carbon dioxide. Flow- closed below a setting that if nitrous oxide is fowing, will meters have, therefore, been introduced that do not have produce less than 25% oxygen in the mixture. Other man- a bezel which can hide the fowmeter bobbin at the top ufacturers use interlinking gears (Fig. This type of mechanical link, however, has 600 ml min–1 from carbon dioxide fowmeters. However, these systems include secondary pressure regulators (see above) in both the oxygen and nitrous oxide systems, the purpose of which is to prevent variations in gas supply pressure from affecting fowmeter performance. Hence a minimum basal fow of oxygen (see (and image manipulated) to better demonstrate double below) or a 50% oxygen ratio at low fows is required. Inward movement of the oxygen of course, can occur only when the machine master switch diaphragm is linked to the opening of a poppet valve that for all the gasses is switched on. This increased machine master switch is turned on, a basal fow rate of oxygen fow is independent of the main oxygen fow 200–300 ml min–1 of oxygen is established (Fig. This alarm is in addition to the stand- also means that rupture of a diaphragm will not result in ard oxygen failure warning device (Ritchie whistle, see contamination of the O2 fow by N2O. Penlon stopped installing this electronic system of hypoxia protection in 2001, largely for reasons of cost, but Electronically controlled anti-hypoxia devices many of their machines are still currently in use with this (Penlon Ltd) technology. If the oxygen concentration falls below 25%, a battery-powered electronic device sounds an audible The back bar alarm and the nitrous oxide supply is cut off. This results in an increase in the oxygen concentration and, as a result, Strictly speaking, the term ‘back bar’ describes the horizon- the nitrous oxide supply is temporarily restored. If the tal part of the frame of the machine, which supports oxygen fow rate has not been increased, the nitrous oxide the fowmeter block, the vaporizers and some other disabling system is reactivated and the alarm will again components. The whole process is repeated, thus providing an include those components and the gaseous pathways intermittent oxygen failure alarm and at the same time interconnecting them. In fact, in modern machines, the assuring a breathing mixture with more than 25% oxygen latter are often housed within the framework. The vaporizers are mounted, either singly or in series, If the oxygen supply fails completely, there is a continu- along the back bar, downstream from the fowmeter block. The power is provided by a maintenance- Traditionally, vaporizers were bolted onto the back bar free lead-acid battery that is kept charged by the mains and linked to each other by tapered fttings. The various electricity supply while the machine is in use and will manufacturers employed different sizes of tapers and continue to operate in the absence of a mains supply for mounting positions but these were superseded by the pro- 1. If for some reason the lead- to a type and size of tapered connection for a reservoir or acid battery is not adequately charged at the beginning rebreathing bag that has a small wire cage ftted to its inlet of an anaesthetic session, the nitrous oxide supply (as well to prevent the neck of the bag from being obstructed, 81 Ward’s Anaesthetic Equipment A Tec 5 off Tec 5 on F G H A E Gas path C D B Station 1 Station 2 Station 3 B C Figure 4. Tec taper for vaporizers, though no longer used in the West, is 3 vaporizers had no safety interlock and this is yet another still in use in many parts of the world. Presently machines are rarely specifed with be removed from the back bar and replaced by those for a three station back bar and this plastic lever is seldom another agent. Ease of removal has resulted Dräger Interlock 2 in a greater fexibility in the choice and use of agents, and The mounting system is similar to the ‘Selectatec’ version, also ensures that anaesthetic machines do not have to be although the dimensions are unique. Problems with detachable vaporizer systems Removable vaporizer systems generate specifc problems: The Ohmeda ‘Selectatec’ System • As mentioned above, there is a greater potential for Each Selectatec station on the back bar has two vertically leaks. Between these inlet • The vaporizer may be accidentally dropped and and outlet ports is an accessory pin and a locking recess. The matching vaporizer assembly has two female ports • Tipping of older models of vaporizer in transit could between which there is a locking assembly and a recess to result in liquid agent entering the bypass system accommodate the pin. The vaporizer is lowered on to the causing either liquid or high concentrations of male valve ports and the locking knob is turned to fx it vapour to be present in the breathing system. The ball valves (which The fowmeter tubes in the fowmeter bank have, as a rule, provide the seals) in the male ports are displaced down- been calibrated for gas fows assuming no downstream wards occluding the back bar, and gas from the back resistance. In a traditional back bar (23 mm internal diam- bar is diverted into the vaporizer (Fig. Gas, fow rates (5–10 l min–1) is marginally above atmospheric therefore, passed through the head of the vaporizer even pressure. However, many modern back bars have narrow when it was not switched on or even locked on. This bore (8 mm) gas passages, which increase fow resistance arrangement obviously had a greater potential for gas and thus back-pressure on the fowmeters. This gas fow (see Chapter 9, Automatic ventilators), increases consists of an extension rod that protrudes sideways back bar pressures. Should station 2 be empty, the lever links the duced does not mean a decrease in the fow of gas to extension rods between vaporizers 1 and 3 to ensure that a patient. It is merely that the gas is compressed at the 83 Ward’s Anaesthetic Equipment higher pressures and subsequently re-expands down- Additional safety features stream when the various resistances have been overcome. Several safety features are installed either on or down- Readjustment of the fowmeters to the original settings stream of the back bar: following an induced pressure rise would therefore be inappropriate. If the outlet is obstructed, Non-return valve the gasses escape at X, so protecting the back bar from Anaesthetic overpressure.

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Emphysema involves gradual destruction of alveolar septae and of the pulmonary capillary bed cheap eldepryl online master card, leading to decreased ability to oxygenate blood buy generic eldepryl 5mg on-line. The body compensates with lowered cardiac output and hyperventilation (puffers) and adequate oxygenation (pink) eldepryl 5 mg mastercard. Eventually eldepryl 5 mg amex, these patients develop muscle wasting and weight loss due to a combination of chronic hypoxia, immobility, and increased metabolic rate. Emphysema is associated with a Pulse oximetry when combined with clinical small heart, hyperinflation, flat hemidiaphragms, observation can be a very useful non-invasive test. Long-term oxygen therapy is the quit” single most effective treatment to improve the Fig. However, regular treatment with there is no step down its always step up (Table inhaled steroid is appropriate for symptomatic 8. Inhaled glucocorticoid combined with long-term decline in lung function that is the long-acting B2 agonist is more effective than hallmark of this disease. Long acting inhaled bronchodilators are population average of about 30 ml/year in more effective and convenient, but more expensive. Combining bronchodilators (β2-agonist, anti- cholinergic, and/or theophylline) may improve the Using spirometry to assess lung age (Fig. Patient should be encouraged to Disadvantage of smoking (pleasure) • Decide a quit date. Even a brief 3 minute period of counseling to urge a smoker to quit can be effective, and at the very least it should done for every smoker at every visit. The provision of smoking cessation support should follow the principles of the ‘five A’ (Ask, Advise, Assess, Assist, Arrange). If a significant portion of the night’s data indicates oxygen saturations below 88%, patients) should be added to counseling if not supplemental nocturnal oxygen can be provided. Compared with months if hypoxia developed during an acute the cost-effectiveness of other medical services for exacerbation. Rechecks should be performed example, breast cancer screening costs up to $26,800 annually if hypoxia is discovered in an outpatient per year of life gained. It can also have with pure sleep apnea tend to resaturate to normal beneficial impact on hemodynamics, exercise between apneas. Arterial prone to the complication like cor pulmonale and blood gas measurement is recommended for polycythemia. Titrate liter-flow to goal at rest breathlessness can provoke anxiety, which can be and add 1 L/min during exercise or sleep or titrate manifest as breathlessness and increased respiratory during exercise to goal of SaO2 greater than 89%. Peripheral muscle conditioning improves patterns through techniques such as guided imagery exercise tolerance. However, before their dried peas and beans (legumes), whole-grain foods, routine use can be recommended, the results of bran, cereals, pasta, rice and fresh fruit should be ongoing trials have to be carefully evaluated. Patients should be asked decrease in severity of exacerbations, but these to take following precautions while having meals: results have not been duplicated. Thus regular use 6 small meals each day, instead of 3 large meals to of this therapy cannot be recommended. By removing a large bulla that does not contribute to gas exchange, the adjacent Mood disorders (depression and anxiety) spell lung parenchyma is decompressed. Most report improvement in signs of respiratory distress is achie- conclude that epidural or spinal anesthesia have ved, or side effects of tachycardia and/or tremor lower risk than general anasthesia, although the develop. Otherwise, the patients before side effects develop, ipratropium bromide should undergo preoperative physiotherapy and should be added to produce additive bronchodila- optimum treatment in order to reduce the risk of tion and allow the use of lower doses of sabutamol, postoperative pulmonary complication. There is no • Moderate to severe dyspnea with use of accessory need to discontinue inhaled steroids while the muscles and paradoxic abdominal motion patient is taking oral prednisone. In fact, the inhaled • Respiratory rate of more than 25 breaths/min steroid may serve as a “systemic-steroid-sparing- • Moderate to severe acidosis (pH of 7. The choice of • Life- threatening hypoxemia (PaO2 < 40mm of Hg or PaO2/FiO2 < 200 mm of Hg antibiotic is controversial, and needs to be tailored • Respiratory arrest to the individual situation. If these fail or failure) the incidence of resistant organisms is high in the • Other complications (metabolic abnormality, sepsis, community or, the use of a “second-line agent” may pneumonia, pulmonary embolism, barotrauma, massive be preferable. Consensus and limited data respiratory failure and the need for noninvasive support the discharge criteria listed in (Table 8. The patient should be followed up after 4 to 6 weeks Ventilatory support includes noninvasive or for assessment given in Table 8. These studies have shown positive results, physiologic impairment (obstructive ventilatory with success rates of 80% to 85%. If the patient does not airway dimensions including luminal area and 238 Textbook of Pulmonary Medicine Table 8. International consensus conferences in intensive care medicine; noninvasive Table 8. Antibiotic benefits therapy in exacerbations of chronic obstructive • Explain about diet, prevention of infections, rehabilitation pulmo-nary disease. Chronic obstructive pulmonary groups, emphysema-dominant and airway disease- disease: prevention, early detection, and aggressive dominant patients, and treat them separately. The word bronchiectasis is derived from the Greek The frequency is estimated to be higher in the roots, Bronchion = Windpipe and Ektasis = stretch- developing world including India where measles, ing out. Bronchiectasis is present when one or more pneumonia, tuberculosis and human immueno- bronchi are abnormally and permanently dilated. First described by Laennec in 1819 and later detailed Cystic fibrosis was thought to be extremely rare in by Sir. However published reports, reviews and undergone significant changes in regard to preva- comments indicate that cystic fibrosis is probably far lence, etiology, presentation and treatment. The precise of children with obstructive pulmonary disease incidence of cystic fibrosis among Indians is being relatively uncommon in developed countries. In one study, the mean With the advent of vaccination and extended age at injury was found to be 20 years, the mean spectrum antibiotics, the prevalence of bronchiectasis age at onset of symptoms was 39 years, and the age has decreased in developed countries. In 1953,the range with the highest frequency of bronchiectasis prevalence of the disease was 1. S, Norman Clark a significant pulmonary insult in their history before estimated an incidence of 06: 10000 in his series the onset of symptoms. Elaine Field closely studied vaccinations and antibiotics the age of presentation children with bronchiectasis in London. Bronchiectasis is an abnormal dilatation of proximal, Therefore a marked fall in the prevalence is seen medium sized bronchi (> 2 mm in diameter) caused in the developed countries, which may be due to by destruction of the muscular and elastic compo- due to more effective treatment of childhood respi- nents of bronchial walls, which can be either congenital or acquired. In 1950, Reid characterized ratory infections (including pneumonia), effective vaccination programs for whooping cough and bronchiectasis as cylindrical, cystic or varicose in measles, decline in prevalence of pulmonary nature. Severe inflammation can lead to necrosis of bronchiectasis has ulceration with bronchial the bronchi focally as in mycobacterium tuberculosis neovascularization and a resultant ballooned or mycobacterium avium-intracellulare pneumonia. Varicose Diffuse damage can occur in inflammatory condi- bronchiectasis has a bulbous appearance and a tions such as cystic fibrosis and allergic broncho- dilated bronchus and interspersed sites of relative pulmonary aspergillosis. The unrelieved, leads to accumulation of mucus, latter subsequently may result in postobstructive distension of the peripheral airways and infection. Other childhood respiratory tract infections like measles may contribute to permanent airway damage. The presence of staphylococcus aureus is associated with cystic fibrosis or allergic bronchopulmonary aspergillosis. Primary mycobacterium avium complex infection has been recognized particularly in white women over 60 years of age, which presents with chronic cough and middle lobe involvement. Bronchiectasis in patients with allergic bronchopulmonary aspergillosis is due to an immune reaction to aspergillus, the actions of mycotoxins, elastase, interleukin-4, interleukin- 5 and in later stages, the direct invasion of the airways by the fungus. Bronchiectasis has been described in patients with the acquired Immuno- deficiency syndrome given their repeated respiratory tract infections and impaired host response. Primary ciliary dyskinesia: Primary ciliary dyskinesia is a prototypical example of a condition in which poorly functioning cilia contributes to the retention of secretions and recurrent infections that in turn lead to Chronic Airway Disorders 241 Table 8. Primary infective insult • Bronchitis, bronchiolitis pertussis, measles, adenovirus pneumonia, tuberculosis B. Genetics, ultrastructural • Primary ciliary dyskinesias (Kartagenars syndrome, Young’s syndrome) C. Immunodeficiency syndromes • Common varied immunodeficiency’s (Congenital and acquired) • Selective immunoglobulin deficiency • Functional immune deficiency • Secondary hypogammaglobulinemia • Human immunodeficiency virus infection D. Autoimmune disease • Inflammation bowel disease • Celiac disease • Systemic lupus erythematosus • Rheumatoid arthritis • Cryptogenic fibrosing alveolitis • Primary biliary cirrhosis • Thyroiditis • Pernicious anemia 2.

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Always add budget for unforeseen conditions/overheads (should not be more than 10% of total budget) purchase generic eldepryl pills. Non-recurring: This head may include building order 5 mg eldepryl visa, instruments/equip- ment discount eldepryl 5 mg without a prescription, vehicle discount eldepryl 5 mg, etc. Overheads (not more than 10% of total budget) Total Budget = Non-recurring + Recurring Example: This is an imaginary budget for a health education drive for population of 100,000. General Administration Rent 6000/m 12 m 72,000 72,000 Water and 5000/m 12 m 60,000 60,000 Electricity Communication 500 1 11 5,500 5,500 -Internet 4. Administrative Meeting expenses 2,000 1 1 2,000 2,000 Offce Stationery 1,000 1 12 12,000 12,000 5. Writing the dissertation in an acceptable format will not only ensure its approval by examiners but will also help the young scientist in writing a good scientific paper. Defnition Dissertation is a treatise or a written composition that deals with a subject formally and systematically. Thesis is a proposition stated especially as a theme to be discussed or proved or maintained against attack or an essay based on research. Dissertation/Thesis are a proof that one cannot only do science, but also write science. I keep six honest serving men They taught me all I know Their names are what, why, when How, where and who. Thus while writing a dissertation the questions what, why, when, how, where and who should be answered. Dissertation/Thesis proposals are designed to: • Justify and plan (or contract for) a research project. Tips to Start Thesis/Dissertation Writing General Advice • Establish a writing schedule, preferably writing at the same time and place each day. Proposal-Specifc Advice • Understand that the proposal will be a negotiated document, so be prepared to draft, redraft, and resubmit it. Annexure Title The title should describe the content in the fewest possible words. The title needs to be accurate, specific, retrievable short yet sufficiently descriptive and as informative as possible. Do not produce long incomprehensible strings and adjectives as seen in this example: “Cytological changes in the conjunctiva in the patients with vitamin A deficiency with or without protein calorie malnutrition”. At the same time the title should not be made meaningless for the sake of brevity as seen in this example “Cell block study”. Thus it is worth analyzing the title and to make sure that it contains elements of the dissertation that it is intended to convey. For example: “Conjunctival Cytology in Xerophthalmia”, “Cell Block Study of Body Fluids”. Introduction The introduction should answer the question “why you want to do the study”? It should introduce the state of knowledge before the work was started, define the gaps in knowledge which the work will fill and state what works set out to do? A good introduction should: • Establish the general territory (real world or research) in which the research is placed. In other words, the introduction needs to provide sufficient background for readers to understand where from your study is coming. Aims and Objectives The objectives of the research project should summarize what is to be achieved by the study. Aim or the General Objective of a study states what is expected to be achieved by the study in general terms. It is possible (and advisable) to break down a general objective into smaller, logically connected parts. It is not necessary to review the entire story of the subject from Pythagoras to the present day but only relevant articles should be reviewed. We know a subject ourselves or we know where we can find the information about it”, said Dr Samuel Johnson. The literature review is a critical look at the existing research that is significant to the work that you are carrying out. Obviously, at this point you are not likely to have read everything related to your research questions, but you should still be able to identify the key texts with which 258 Research Methodology for Health Professionals you will be in conversation as you write your dissertation/thesis. Literature reviews often include both the theoretical approaches to your topic and research (empirical or analytical) on your topic. Writing the Literature Review Allows Understanding • How other researchers/scholars have written about the topic? The literature review has four major functions that you should keep in mind as you write: • It situates the current study within a wider disciplinary conversation. Effective Literature Reviews Should– • Take out the Introduction’s brief description of the background of your study. Tips on Drafting Your Literature Review • Categorize the literature into recognizable topic clusters and begin each with a sub-heading. Demonstrate the places where the literature is lacking, whether due to a methodology you think is incomplete or to assumptions you think are flawed. You should be tying the literature you review to specific facets of your problem, not to review for the sake of reviewing. As tempting as it might be to throw in everything you know, the literature review is not the place for such demonstration. Stick to those pieces of the literature directly relevant to your narrowed subject (question or statement of a problem). You should fight the temptation to strongly express your opinions about the previous literature. Your task is to justify your project given the known scholarship, so polemics, praise, and blame are unnecessary and possibly distracting. Key Points: After assessing the literature in your field, you should be able to answer the following questions: • Why should we study (further) this research topic/problem? Materials and Methods This section is essential and important to most good research proposals. This section includes a description of the general means through which the goals of the study will be achieved: Methods, materials, procedures, tasks, etc. An effective methodology section should: • Introduce the overall methodological approach for each problem or question. Are you going to take a special approach, such as action research, or use case studies? Your methods should have a clear connection with your research questions and/or hypotheses. In other words, make sure that your methods will actually answer your questions or stated objectives, i. One should also include inclusion, exclusion, eligibility and diagnostic criteria especially in medical and health research. Will you use specific theoretical perspectives to help you analyze a text or explain observed behaviors? For instance, if you propose to conduct interviews and use questionnaires, how do you intend to select the sample population? The description of the results of your work is the heart of your thesis/dissertation. In this section you might like to include illustrations, like photograph, sector graphs histograms, pie charts, tables and so on. Remember that illustrations should not be used as ornaments but should support the text and aid in clear description and concise explanations, use them to help convey the information accurately and succinctly. All photographs should have a figure number written in Arabic numerals a short caption or legend and in case of photomicrographs the stain used and magnification should be written, e. Punctuators particularly commas, full stops and quotation marks should be used carefully as wrong usage can alter the meaning totally for example– Go, slow work in progress. It is in the discussion that the author incorporates his contribution into existing knowledge.

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