Environmental health officers technically suggest comments and follow its implementation to make the working places more comfortable generic 1mg estradiol with amex. The environmental health officers are most needed here to apply their expertise knowledge of housing and institutional sanitation estradiol 2 mg amex, nutrition and food hygiene and safety discount estradiol 1 mg mastercard, environmental chemistry. Post – test First try to look and do the pretest again, then keep on attempting the following questions. Thus, today there has been a strong commitment from the government side to realize the policy and protects the public health. It is one part of the strategies of national health policy to train the health extension workers as a front line community health personnel in the regional health institutions with the intent that after the end of their training they will go near to the community that is rural areas and they fight with the nation public health challenges together with their professional colleagues in the interdisciplinary approach. It provides basic information on different aspects of diabetes so that they participate in early case detection, case management and prevention of complications as front line health workers. Directions for using the module Before starting to read this module, please follow the instruction given below. Self- Monitoring of glucose Many patients (especially those with type 1(insulin- dependent diabetes mellitus)) now regularly monitor their own blood glucose concentrations on the advice of their health care provider, using reagent test strips and reflectance meter. Several companies manufacture reagent test strips for monitoring blood glucose, and most of these companies make reflectance meters to be used to electronically read the test result. The strips used for these tests are impregnated with the enzyme glucose oxidase, enzyme peroxidase and an indicator to give a color change that is detectable. Urine Glucose determinations Chemical screening tests for glucose (dextrose) are generally included in every routine urinalysis. The occurrence of glucose in the urine indicates that the metabolic disorder diabetes mellitus should be suspected, although several other conditions result in glycosuria (glucosuria). It is possible to use both enzymatic technique and oxidation- reduction technique to determine urine glucose 2. Glucose oxidase will oxidize glucose to gluconic acid and at the same time reduce atmospheric oxygen to H2O2. The hydrogen peroxide formed will, in the presence of the oxidized form, which is indicated by the color change of an oxidation- reduction indicator. Note: The glucose oxidase, peroxidase and the reduced form of the Oxidation- Reduction indicator are all impregnated on to a dry reagent strip. After one minute read the result by matching the color on the strip with the color on the reagent strip container 7. Determination of ketone bodies in urine ketone bodies are a group of three related substances: acetone, aceto acetic acid, and β – hydroxyl butyric acid. When ever fat (rather than carbohydrate) is used as the major source of energy, ketosis and ketonuria may result. The two out standing causes of ketone accumulation are diabetes mellitus and starvation In diabetes mellitus, the body is unable to use carbohydrate as an energy source and attempts to compensate by resorting to fat catabolism, which results accumulation of ketone more than normal, that the body is unable to utilize it. The clinical result is an increased concentration of ketones in the blood (ketonemia) and in the urine (ketonuria. After collecting the urine sample from the patients, transfer into a clean, dry and free of disinfectant test tube 2. Read the result by comparing the color produced with the standard on the strip container Note acetone and aceto acetic acid can be detected by different dip stick tests, but there is no reagent strip test for β - hydroxyl butyric acid 115 4. Determination of urine protein Microalbuminuria • Diabetes mellitus causes progressive changes to the kidneys and ultimately results in diabetic renal nephropathy. This complication progresses over a period of years and may be delayed by aggressive glycemic control • An early sign that nephropathy is occurring is an increase in urinary albumin • It is thought that the early development of renal complications can be predicted by the early detection of consistent micro albuminuria. And this early detection is desirable, as better control of blood glucose levels may delay the progression of renal disease 4. Tests that are based on the precipitation of protein by chemical or coagulation by heat - This test will detect all proteins, including albumin, glycoproteins, globulins, Bence Jones protein & hemoglobin 4. The general recommendation include consumption of a balanced health diet composed of the following • 50% to 60% of calories be derived from carbohydrates • Less than 30% from fat & • The remaining 10% to 20% from protein *Food which diabetic should avoid (rapidly absorbed carbohydrate) 1) Sugar, honey, jam, marmalade &candy 2) Cakes & sweat biscuits 3)Soft drink (Fanta, cocacola etc) 4) Alcohol (Cognac, tej, arki, whisky) There are alcohols, which are allowed in moderation, that is, less sweat drinks i. Exercise - Is extremely important in the management of diabetes because of its effect on lowering blood glucose and reducing cardiovascular risk factors -Lowers blood glucose level by increasing the uptake of glucose by body muscles and by improving insulin utilization - Pre or post exercise snack may be required to prevent hypoglycemia after exercise - Patients should be thought to do regular, moderate exercise at the same time (preferably when blood glucose level are at their peak) and in the same amount for at least 30 minutes each day. Monitoring of Glucose and Ketones Blood glucose level and urine for ketone and glucose should be assessed frequently by self or by having follow up in the health unit Pt education -about Insulin Injection - Insulin injections are administered into the subcutaneous tissue - Equipment: - Insulin - Short acting insulin is clear in appearance and long acting insulin are cloudy and white - The long acting must be mixed (gently inverted or rolled in the hands) before use o - Before injection it should have room T which may require rolling it in the hands or removing it from a refrigerator for a time before the injection - If a frosted, adherent coating is present, some of the insulin is bound and should not be used Syringes - should be matched with the insulin concentration - 1 ml syringes – hold 100 units - ½ ml syringes – hold 50 units - 3/10 ml syringes – hold 30 units Administering the injection -Avoid use of alcohol for cleansing - Four main areas • Abdomen • Arms (posterior surface) • Thighs (anterior surface) • Hips 120 Absorption is greatest in abdomen and decreases progressively in the arm, thigh, and hips Rotation - Rotation of injection site is required to prevent lipodystrophy, localized changes in fatty tissue, Pt is instructed as: - 1. Systemic allergic reaction - are rare - local skin reaction that gradually spreads in to generalized urticaria Treatment:- desensitization , gradually increasing the amount of insulin 3. High-risk individuals should be encouraged to • Maintain a normal body mass index • Engage in regular physical exercise No specific intervention is proven to prevent type 2 diabetes mellitus. Braunwald, Fauci, Kasper, Hauser, Longo, Jameson:Harrison’s Principles of th Internal medicine, 15 Edition 12. Links or references to nonfederal organizations mentioned in this book or in the resource list are provided solely as a service to our users. This book is dedicated to all people living with diabetes, in honor of your struggles and your strength. People with diabetes often have stories to share about their struggles for balance and harmony in their lives. We can honor people by listening to and learning from their stories to fnd meaning and hope for our own lives. An old, well-loved story, told around the world, is about the turtle and a sure-footed animal, like a rabbit. In this story, the turtle tricks the other animal to win a race—simply by not giving up and by staying on its path. It takes determination like that to face diabetes, day after day, reminding yourself that you can do it if you stick to it! There are about 250 kinds of turtles, and almost all have the same pattern on their top shell—13 plates that ft together in harmony and balance to form a strong shell. The turtle and its shell can remind us of the harmony and balance we seek in all parts of our lives—including living with diabetes. The division is part of the National Center for Chronic Disease Prevention and Health Promotion, Department of Health and Human Services. We asked people with diabetes who read the frst book to help us make the second book even more useful. The American Association of Diabetes Educators did a survey among people with diabetes and diabetes educators to learn what people liked and didn’t like about the frst book. Conducted by the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, this important study provided scientifc proof that glucose control can help prevent or delay complications of diabetes. Ann Constance, Claudia Martinez, Hope Woodward, Margaret Fowke, Nancy Haynie- Mooney, Melinda Salmon, Mike Engelgau, and the Chattahoochee Nature Center also helped with the writing. Rick Hull, Diana Toomer, Melissa Stankus, and Kristina Ernst reviewed and edited the fnal version of this guide. You may even want to join a community group in which people share their stories and help others deal with their diabetes. It’s important to work with a primary health care provider, as well as other members of a team who Work with your health care team to take charge of your diabetes. To fnd out about resources in your community, contact one of the groups listed below: ■ Diabetes organizations, listed on pages 127–129 of this book. With the support of your family and friends, your health care team, and your community, you can take charge of your diabetes. See the list beginning on page 127 for phone numbers, addresses, and web sites of organizations where you can get more information. Find out as much as you can about the three most important things for controlling your diabetes: food, physical activity, and diabetes medicine. There’s enough room on these pages to write questions and other points you want to remember when you go to your visits every 4 to 6 months. Harper Telephone number: ________________________________222-222-2222 Your questions: ___________________________________ _________________________________________________What was my last A1C result? The pancreas, an organ near the stomach, makes a hormone called insulin to help glucose get into our body cells. When you have diabetes, your body either doesn’t make enough insulin or can’t use its own insulin very well. Signs and Symptoms of Diabetes You may recall having some of these signs before you found out you had diabetes: ■ Being very thirsty. Scientists are learning more about what causes the body to attack its own beta cells of the pancreas (an autoimmune process) and stop making insulin in people with certain sets of genes.

The issue is complicated further because different allelic mutations in the same gene can produce different phenotypes generic 1mg estradiol overnight delivery. For example discount 1 mg estradiol, different mutations in the alpha subunit can produce Tay-Sachs disease buy 2 mg estradiol fast delivery, a late infantile variant, a juvenile variant that clinically mimics spino-cerebellar degeneration, and an adult variant that looks like a motor neuron disease. Mucopolysaccharidoses: These are caused by mutations in enzymes that catabolize mucopolysaccharides, large molecules that are components of many organs. Thus, the clinical and pathological manifestations of these diseases are far more widespread than those of the gangliosidoses. Typical manifestations include hepato- and splenomegaly, joint and bone deformities, opacities of the lens and cornea, connective tissue abnormalities, and storage of mucopolysaccharides in neurons. Hydrocephalus is also common, due to mucopolysaccharide deposition in the meninges with resultant deficits in the circulation and resorption of cerebrospinal fluid. Three typical variants: infantile (chromosome 1) late infantile, and juvenile (chromosome 16) and an adult form are known. As in many of the storage diseases, the infantile form is the most severe and rapidly progressive. The diagnosis rests on clinical patterns and genetic testing, although the demonstration of typical intracellular inclusions by fluorescence and electron microscopy in neurons, skin, muscle, or white cells can be helpful in narrowing down the diagnosis. Leukodystrophies: As the name indicates, these are disorders that preferentially affect white matter and may be included under Diseases of Myelin. Since oligodendrocytes or myelin sheaths are affected, patients display a loss of myelin or abnormal myelination. Typically, they show neurological signs referable to white matter destruction, such as spasticity. Very long chain fatty acids, normally degraded in peroxisomes, are elevated or "stored" in brain and other organs, particularly the adrenal cortex. This disease was most commonly related to hemolysis from Rh incompatibilities but any source of hemolysis results in the presentation of excessive bilirubin to immature hepatic cells lacking sufficient glucuronyltransferase activity for conjugation. Therefore, large amounts of indirect or unconjugated bilirubin accumulate in blood. The incidence of kernicterus has been greatly reduced due to the decrease in hemolytic jaundice of the newborn. These infants also have superimposed anemic and oligemic hypoxia due to hemolysis and problems with cardiac function. Consequently, the lesions are thought to result from both unconjugated hyperbilirubinemia and hypoxic/ischemic damage to "old" neuronal groups, which are active metabolically at birth. Children who survive the kernicteric episode develop the classical triad of opisthotonus, sensorineural deafness and defective ocular supraversion. Episodic attacks (often following the use of barbiturates or sulfonamides) of emotional instability, sleeplessness, severe pains of abdomen, back, and limbs and vomiting commence in the postpubertal period. All, except the chromatolytic lesions, are believed to be hypoxic-ischemic in origin. Chromatolysis of anterior horn motor and dorsal root ganglion neurons is secondary to a distal axonopathy of peripheral nerve. This is a disease in which copper levels are elevated in organs, particularly liver and brain. Serum ceruloplasmin (a copper binding protein) and serum copper are low, while tissue copper is elevated. Neuropathologic lesions are concentrated in the basal ganglia where one finds subtotal rarefaction with neuronal loss to complete necrosis with astrocytosis and eventual atrophy. Excessive copper has been identified in the basal ganglia, probably within glial cells. These enzyme deficiencies lead to neuronal degeneration and mental retardation, abnormal hair, hypopigmentation, and vascular disease due to abnormal collagen formation. Tremors and profound alterations in consciousness are poorly reflected by the paucity of neutropathologic lesions. This change should not be confused with the Alzheimer changes of neuritic plaques and neurofibrillary degeneration. Patients with profound uremia as a result of end stage renal disease may also develop an encephalopathy with depression of consciousness. The exact pathogenesis is unclear, but it is usually seen in the setting of viral infection and treatment with aspirin. Since aspirin has been contraindicated in children suffering from viral illnesses, the incidence has fallen off dramatically. Neuropathologic changes are nonspecific in that the brain shows evidence of cerebral edema and subsequent herniation. Ultrastructural examination of both liver and brain has revealed abnormal swollen and pleomorphic mitochondria. Individuals who abuse ethanol show a constellation of neurologic signs and symptoms to the metabolic consequences of ethanol abuse. It is difficult to decide whether the metabolic lesions commonly seen in alcoholics are the result of the toxic effects of ethanol, poor nutrition, or a combination of factors. Patients who die of acute ethanol intoxication reveal nonspecific changes of cerebral congestion, edema and punctate hemorrhages. Likewise, there is no characteristic pathologic change associated with delirium tremens or withdrawal seizures (rum fits). Vermal atrophy is due to loss of Purkinje cells and internal granular neurons with atrophy of molecular layer. Alcoholic cerebral atrophy, however, is a more variable lesion, initially affecting the dorsolateral aspects of the frontal lobes. There is considerable evidence to suggest that there is an alcoholic dementia that is distinct from the Korsakoff psychosis. This is the time when the neural fold develops, the underlying mesodermal structures develop (these will form the protective structures enclosing the nervous system), and the neural tube forms. Normally, the anterior closure of the neural tube has taken place by the 26th day, the posterior closure by about the 28th day. In anencephaly, the cord, brain stem, and cerebellum are often intact, but above these lie only small amounts of disorganized neuronal-glial and vascular tissues (‘area cerebrovasculosa’). This absence of brain tissue is associated with a deficiency or under- development of the squamous bones of the cranial vault (acrania). Eyes are present (optic vesicles form at day 18) and usually normal; these infants typically have protruding “toad’s head” exophthalmic eyes associated with shallow orbits. In more severe cases, the neural tube defect may also involve the midbrain, pons and cerebellum, and these structures may thus also be absent or partially present. Anencephalics are either still born or die within a few days after birth, with cardiac and respiratory function dependent on presence of hindbrain structures. This results in a cleft or defect in bone through which dura, meninges, and brain or cord may herniate. In a meningocele, dura and meninges protrude through a posterior defect in spinal bone. In a myelomeningocele, dura, meninges, spinal roots with and without the cord protrude. An encephalocele is a protrusion of dura, meninges, and brain tissue through a defect in the skull. In spina bifida occulta, there are malformed spinal arches, but no herniation of dura, meninges, or cord takes place. Neural Tube Defects Disease Clinical Features Pathologic Features Pathogenesis > Incompatible with > Most of intracranial contents > Failure of anterior independent existence. Variable by ultrasound, raised α- > Folic acid deficiency extension to spinal cord. Syringomyelia is a cystic cavity in the center of the cord, often in the cervical region. This leads to damage of crossing sensory fibers (pain and temperature), but spares posterior column function. As the cavity enlarges, it may encroach on anterior horns and pyramidal tracts, leading to motor dysfunction. Although many syrinxes are thought to be congenital, they do not usually become symptomatic until early adulthood. Some authorities do not distinguish between syringomyelia and hydromyelia, but consider them to be variations along a spectrum of one disorder. The brainstem is displaced so much that the lower cranial nerves actually course upward.

Cardiac Anatomy ▪ 2 upper chambers ▪ Right and left atria ▪ 2 lower chambers ▪ Right and left ventricle ▪ 2 Atrioventricular valves (Mitral & Tricuspid) ▪ Open with ventricular diastole ▪ Close with ventricular systole ▪ 2 Semilunar Valves (Aortic & Pulmonic) ▪ Open with ventricular systole ▪ Open with ventricular diastole The Cardiovascular System ▪ Pulmonary Circulation ▪ Unoxygenated – right side of the heart ▪ Systemic Circulation ▪ Oxygenated – left side of the heart Anatomy Coronary Arteries How The Heart Works Anatomy Coronary Arteries ▪ 2 major vessels of the coronary circulation ▪ Left main coronary artery ▪ Left anterior descending and circumflex branches ▪ Right main coronary artery ▪ The left and right coronary arteries originate at the base of the aorta from openings called the coronary ostia behind the aortic valve leaflets estradiol 1mg sale. Sinus bradycardia is often seen as a normal variation in athletes purchase 2mg estradiol visa, during sleep buy estradiol 1mg low cost, or in response to a vagal maneuver. Sinus Arrest or Pause A sinus pause or arrest is defined as the transient absence of sinus P waves that last from 2 seconds to several minutes. The ventricles do not receive regular impulses and contract out of rhythm, and the heartbeat becomes uncontrolled and irregular. Frequently is seen as the last-ordered semblance of a heart rhythm when resuscitation efforts are unsuccessful. Torsades usually terminates spontaneously but frequently recurs and may degenerate into ventricular fibrillation. Rhythm Identification ▪ This rhythm strip is from an 86-year-old woman who experienced a cardiopulmonary arrest. Rhythm Identification ▪ This rhythm strip is from a 69-year-old man complaining of shortness of breath. Rhythm Identification ▪ This rhythm strip is from a 52-year-old man found unresponsive, apneic, and pulseless. Rhythm Identification ▪ These rhythm strips are from a 78-year-old man complaining of shortness of breath. Rhythm Identification ▪ This rhythm strip is from an 86-year-old woman complaining of chest pain that she rates a 4 on a scale of 0 to 10. Rhythm Identification ▪ This rhythm strip is from an 88-year-old woman complaining of hip pain after a fall injury. Rhythm Identification ▪ This rhythm strip is from an 18-year-old man with a gunshot wound to his chest. In mammals, glucose is the preferred fuel source for the brain and the only fuel source for red blood cells. The glycolytic pathway is common to virtually all organisms Both eukaryotes and prokaryotes In eukaryotes, it occurs in the cytosol 7 1. Glyceraldehyde 3-Phosphate Dehydrogenase Energy transformation: Phosphorylation is coupled to the oxidation of glyceraldehyde 3-phosphate. Glyceraldehyde 3-Phosphate Dehydrogenase Energy transformation: Phosphorylation is coupled to the oxidation of glyceraldehyde 3-phosphate. Glyceraldehyde 3-Phosphate Dehydrogenase The enzyme-bound thioester intermediate reduces the activation energy for the second reaction: 24 1. Phosphoglycerate Mutase The next two reactions convert the remaining phosphate ester into a phosphate having a high phosphoryl transfer potential The first is an isomerization reaction 26 1. Enolase The next two reactions convert the remaining phosphate ester into a phosphate having a high phosphoryl transfer potential The second is a dehydration (lyase) reaction 27 1. Maintaining Redox Balance The solution to this problem lies in what happens to the pyruvate that is produced in glycolysis: Fermentation Pathways 32 1. Maintaining Redox Balance Lactic acid fermentation is use by bacteria and human muscles and produces lactate. Usually due to loss of uridyl transferase activity Symptoms include Failure to thrive infants Enlarged liver and jaundice, sometimes cirrhosis Cataracts Mental retardation 41 2. Control of Glycolysis In metabolic pathways, control is focused on those steps in the pathway that are irreversible. Control of Glycolysis The different levels of control have different response times: Level of Control Response Time Allosteric milleseconds Phosphorylation seconds Transcriptional hours 44 2. Fructose 2,6-bisphosphate A regulated bifunctional enzyme synthesizes and degrades fructose 2,6-bisphosphate: 49 2. The brain has a strong preference for glucose, while the red blood cells have and absolute requirement for glucose. Gluconeogenesis The three kinase reactions are the ones with the greatest positive free energies in the reverse directions 54 3. Gluconeogenesis The hexokinase and phosphofructokinase reactions can be reversed simply with a phosphatase 55 3. Formation of Phosphoenopyruvate The conversion of pyruvate into phosphoenolpyruvate begins with the formation of oxaloacetate. Oxaloacetate Shuttle Oxaloacetate is synthesized in the mitochondria and is shuttled into the cytosol where it is converted into phosphoenolpyruvate 60 3. Regulation of Glycolysis and Gluconeogenesis Reciprocal regulation of glycolysis and gluconeogenesis in the liver 62 4. Evolution of Glycolysis and Gluconeogenesis Glycolysis and Gluconeogenesis are evolutionarily intertwined. Therapy for Anaphylactoid Reactions  Bronchosapsm  Minor-Uticaria, with or  Oxygen without Skin Itching  Mild- albuterol inhaler, 2 puffs  No therapy  Moderate-Epinephrine 0. Patients with prior evidence of an anaphylactoid reaction to contrast media should receive appropriate steroid and antihistamine prophylaxis prior to repeat contrast administration. In patients with prior history of allergic reactions to shellfish or seafood, anaphylactoid prophylaxis for contrast reaction is not beneficial. Patients undergoing cardiac catheterization with contrast media should receive adequate preparatory hydration. In patients with chronic kidney disease (creatinine clearance <60cc/min), the volume of contrast media should be minimized. Patient  Total Air Kerma at the Interventional Reference Point (K , a,r Dose Gy) is the x-ray energy delivered to air 15cm from for patient dose burden Assessment for deterministic skin effects. The Procedure/Patient  As patient size increases…  Image quality poor  Input dose of radiation increases exponentially  Scatter radiation more  As complexity increases. Procedure Related Issues to Minimize Exposure to Patient and Operator  Utilize radiation only when imaging is necessary  Minimize use of cine  Minimize use of steep angles of X-ray beam  Minimize use of magnification modes  Minimize frame rate of fluoroscopy and cine  Keep the image receptor close to the patient  Utilize collimation to the fullest extent possible  Monitor radiation dose in real time to assess patient risk/benefit during the procedure Tube Position and Scatter The scatter profile tilts as the x-ray tube is moved from the posterior to the anterior projection or when the tube is moved toward the cranial or caudal projections. Procedure Related Issues to Specifically Minimize Exposure to Operator  Use and maintain appropriate protective garments  Maximize distance of operator from X-ray source and patient  Keep above-table and below-table shields in optimal position at all times  Keep all body parts out of the field of view at all times Inverse Square Law 2 2 I / I = (d ) / (d ) 1 2 2 1 This relationship shows that doubling the distance from a radiation source will decrease the exposure rate to 1/4 the original. Staff Radiation Protection  Shielding  Lead>90%;Proper care of aprons  Thyroid shielding; <40 yo The Next Armani? Staff Exposure Limits  Whole Body 5 rem (50 mSv)/yr  Eyes 15 rem (150 mSv)/ yr  Pregnant Women 50 mrem (0. Risk Management of Skin Effects in Interventional Procedures  Individualized management by an experienced radiation wound care team should be provided for wounds related to high dose radiation. M alalignment of the teeth such as crowding, abnormal the teeth that results in localized dissolution and destruction spacing, etc. It is the second m ost com m on cause of tooth loss and is found universally, irrespective of age, Saliva5–8 sex, caste, creed or geographic location. N orm ally, 700– be a disease of civilized society, related to lifestyle factors, 800 ml of saliva is secreted per day. Eating fibrous food severe pain, is expensive to treat and leads to loss of precious and chewing vigorously increases salivation, which helps m an-hours. Aetiology • Q uantity:Reduced salivary secretion as found in xerostomia An interplay of three principal factors is responsible for and salivary gland aplasia gives rise to increased caries this m ultifactorial disease. Host factors • Antibacterial factors: Saliva contains enzym es such as lactoperoxidase, lypozym e, lactoferrin and im m uno- Teeth1–4 globulin (Ig)A, which can inhibit plaque bacteria. As teeth get ferment carbohydrate foodstuffs, especially the disaccharide worn (attrition), caries declines. The dental plaque holds the Centre for Dental Education and Research acids produced in close contact with the tooth surfaces All India Institute of M edical Sciences, N ew Delhi 110029 and prevents them from contact with the cleansing action e-m ail: nshah@aiim s. Tooth • Poor contact between the teeth resulting in food • Socioeconomic status • Structure·fluoride content and other trace impaction and caries due to the following • Literacy level elements such as zinc, lead, iron causes • Location·urban, rural • Morphology·deep pits and fissures ·malalignment of the teeth (crowding) • Age • Alignment·crowding ·loss of some teeth and failure to replace them • Sex 2. Microorganisms·dental plaque accumulation • Gingival recession leading to root caries • Dietary habits due to poor oral hygiene • Climatic conditions and soil type 3. Diet • Social and cultural practices • Intake of refined carbohydrates such as • Availability/access to health care facility sucrose, maltose, lactose, glucose, fructose, • Health insurance cooked sticky starch, etc. The role of refined carbohydrates, especially the disac- • Fem ales develop caries m ore often than m ales. The total am ount consum ed as well as the • Availability/access to a health care facility can affect physical form , its oral clearance rate and frequency of utilization of health care services.

I feel to express my heartfelt appreciation to my grandparents who envisioned and upheld an uncompromising goal in life order estradiol 1 mg with mastercard, which was “to be what you want to be at any place in this world” buy cheap estradiol 2 mg. Thank you Jim for your revision of the thesis and your much appreciated comments which were taken into consideration throughout the dissertation buy estradiol 1mg low cost. John, many thanks for your comprehensive revision of the thesis and for your much appreciated comments which definitely were taken into consideration throughout the thesis. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. Experience with spiral computed tomography as the sole diagnostic method for traumatic aortic rupture. Prospective study of blunt aortic injury: multicenter trial of the American Association for the Surgery of Trauma. Emergency room thoracotomy for the resuscitation of patients with ´fatal´ penetrating injuries of the heart. A ruptured thymic branch aneurysm mimicking a ruptured aortic aneurysm, with associated bronchial artery aneurysms: Report of a case. Surgical management of ruptured descending thoracic aneurysm with massive extrapleural hematoma [in Japanese]. Prospective study of the effect of safety belts on morbidity and health care costs in motor-vehicle accidents. Cardiac herniation with catheterization of the heart, inferior vena cava, and hepatic vein by a chest tube. Endovascular Graft Committee: guidelines for development and use of transluminally placed endovascular prosthetic grafts in the arterial system. Penetrating atherosclerotic aortic ulcer with dissecting hematoma: control of bleeding with percutaneous embolization. One of the Although huge extrapleural hematoma extrapleural hematoma was 34 of 477, common injuries to the chest, particularly can cause ventilatory and circulatory dis- 7. The incidence of thoracic lesions rib fracture, hemothorax, lung contusion, turbances and even death, it has received was 86 of 34 5 2. Cer- whereas the incidence of extrathoracic geon with a reliable clinical clue that the tain basic and modern facts need to be lesions was 30 of 34 5 0. A thoracotomy was used suc- Key Words: Extrapleural hema- study was undertaken to analyze the inci- cessfully to remove a huge hematoma in toma, Subpleural/retropleural/epipleural dence, diagnosis, management, morbidity, one patient. One such compli- women, ranging from 29 to 87 years with an average age of cation is pleural disorder. When there is examined patient age, gender, mechanism of injury, comor- blood in the intrapleural space, the term hemothorax is used, bidity, clinical diagnosis, radiologic diagnosis, associated in- whereas there is no appropriate scientific term nor nomen- juries, complications, treatment, length of hospital stay in the clature for bleeding in other abnormal spaces in the chest intensive care unit and the ward, and follow-up. Follow-up of these patients showed that the most common complication was pain in six patients, chest- tube complications in three, and sternal hematomas in two. Two cases were called “extrapleural,” and one case was named both “extrapleural” and “subpleural” by two different Fig. According to a standard medical dictionary,30 toma that has a D-shaped outline with its base located against the the word “subpleural” is defined as located beneath the corresponding part of the chest wall. The pleural reflection at the pleura, “extrapleural” is described as outside the pleural cav- lower margin of the lesion is seen, and the costophrenic angle is not ity, and “epipleural” is described as located on a pleural obliterated. Associated rib fractures were found in 30 of 34 was called “extrapleural fluid” by Smedal and Lippincott in (88. More than half of the patients had an associated 2 3 1950 and “retropleural hematoma” by Scheff et al. These to 48 hours after admission in 30 patients, but delayed 5 days terms are almost unknown in our practice of cardiothoracic in 1 patient and 10 days in 3 patients. Of these four patients, and trauma surgery, probably because of the unrecognized there were only two patients with associated hemothorax: this significance of epipleural or subpleural bleeding. Retropleural is not informative enough ment was given), and we found that no patient developed a because the pleura turns itself, and what is called retropleural delayed hemothorax. Conservative treatment with observation and chest radio- graph control was provided in 33 patients, and 1 patient Classification needed a thoracotomy to evacuate the hematoma after unsuc- We suggest the following simple etiologic classification cessful needle aspiration. Blunt thoracic injury begins with fractures of the ster- the aortic wall, including the pleural spaces and mediastinum. We completed an angiogram of the aortic arch in origin of blood is usually intercostal or internal mammary three cases with suspected widened mediastinum, but this vessels. A history of surgery, thickening of the overlying pleura that persists for 2 years or particularly that of open sympathectomy1–3 and lung more. Extrapleural tumor risk factors such as old age with tortuous vessels, skeletal could be even more confusing to diagnose if it is discovered deformity such as scoliosis, other comorbidity such as neu- after trauma. A pleural thoracostomy drainage might prove unsatisfactory when the thickening that does not shift with gravity could be a clotted hematoma is clotted. Therefore, the recognition mended, and one may observe the recently described “dis- and the proper treatment of such a rare entity is important. Such a bleeder, 288 August 2000 Traumatic Extrapleural Hematoma however, could be identified using thoracic artery angiogram retropleural hematomas following sypathectomy. Life-threatening hemorrhage from ered the preferred approach for the management of pleural inadvertent cervical arteriotomy. An unusual complication of fractures, hemothorax, lung contusions, pneumothorax, and percutaneous catheterization of the internal jugular vein. Epipleural hematoma: etiology, extrathoracic injuries were cerebral concussion and clavicular morphology and clinical course [in German]. Although huge extrapleural hematoma might cause ven- complication after blunt thoracic trauma [in German]. Unusual clinical forms mothorax, lung contusion, and pneumothorax might provide of extrapleural (epipleural) hematoma on the chest x-ray [in the surgeon with a reliable clinical clue that the patient is at German]. Extrapleural hematoma: a discomfort and a transient rise in temperature but has less recognizable complication of central venous pressure monitoring. Extrapleural hematoma following implying greater blood loss, can produce dyspnea or become 13 infraclavicular subclavian vein catheterization [letter]. Left extrapleural of intrathoracic lesions such as neurofibroma if it is found in hemothorax from rupture of the subclavian artery. Pleural complications Primary hemangiopericytoma of the chest wall: a case report [in in lung transplant recipients. Subjects: 418 patients with blunt chest trauma of whom 29 had a fractured sternum (11 with retrosternal haematoma and 18 without) and 389 did not (7 with widened mediastinum and 382 without). Results: Retrosternal haematomas were found adjacent to many fractures and ranged in size from a few mm to 2 cm. There was no signiŽ cant difference in the number of associated lesions between patients with sternal fractures with or without a retrosternal haematoma. Conversely, patients with a widened mediastinum had a higher injury severity score, longer hospital stay (p < 0. Six patients still had pain 1 month after injury of whom two had injury-related long-term disability because of pain. The early mortality in our study was 2/29 in patients with sternal fractures and 1/7 in patients with widened mediastinum. An aggressive approach including early operative reduction is recommended even for a stable fracture to reduce the overhelming pain. Sternal fracture with or without retrosternal heamatoma is not a reliable indicator of cardiac and aortic injuries, while mediastinal widening is still a fairly reliable clue that should indicate further investigation. Key words: sternal fractures, retrosternal hematoma, mediastinal widening, diagnosis, management, morbidity and mortality, cardiac and aortic injuries. One of our main aims Most chest injuries involve soft tissue, the bone cage, was to Ž nd out if the presence of a sternal fracture and the underlying pleura and lung, and chest wall indicates cardiac and aortic injuries and to clarify the injuries make up a half to two thirds of all thoracic difference between a retrosternal haematoma and injuries that require admission to hospital. The age, sex, should suspect and assess any underlying injuries to the mechanism of injury, comorbidity, clinical diagnosis, heart, bronchus, and great vessels. Reports about radiological diagnosis, associated injuries, complica- sternal fractures are almost always contradictory tions, treatment, length of hospital stay, and follow-up (3, 5, 7, 9, 12, 15). Because most of them are chest trauma of whom 29 patients (range 30–92 years, associated with the steering wheel type of injury the mean age 64, 17 women and 12 men) had a fractured mortality rate may be high because of the severity of sternum (11 with retrosternal haematoma and 18 associated cardiovascular injuries. We therefore con- without) and 389 did not (7 with widened mediastinum ducted this retrospective study to look at the incidence, and 382 without).

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