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Adverse Events of Intravesical Onabotulinum Toxin A Injection between Patients with Overactive Bladder and Interstitial Cystitis-Different Mechanisms of Action of Botox on Bladder Dysfunctionfi Botulinum toxin type A injection for refractory interstitial cystitis: A randomized comparative study and predictors of treatment response. Intravesical botulinum toxin-A injections reduce bladder pain of interstitial cystitis/bladder pain syndrome refractory to conventional treatment A prospective, multicenter, randomized, double-blind, placebo-controlled clinical trial. Long-term efficacy and safety of repeated intravescial onabotulinumtoxin A injections plus hydrodistention in the treatment of interstitial cystitis/bladder pain syndrome. Persistent therapeutic effect of repeated injections of onabotulinum toxin A in refractory bladder pain syndrome/interstitial cystitis. The functional results of partial, subtotal and total cystoplasty with special reference to ureterocaecocystoplasty, selective sphincterotomy and cystocystoplasty. Treatment of interstitial cystitis: comparison of subtrigonal and supratrigonal cystectomy combined with orthotopic bladder substitution. Urinary conduit formation using a retubularized bowel from continent urinary diversion or intestinal augmentations: ii. Circumcision plus antibiotic, anti-inflammatory, and alpha-blocker therapy for the treatment for chronic prostatitis/chronic pelvic pain syndrome: a prospective, randomized, multicenter trial. Prospective double-blind preoperative pain clinic screening before microsurgical denervation of the spermatic cord in patients with testicular pain syndrome. Twelve-year outcomes of laparoscopic adhesiolysis in patients with chronic abdominal pain: A randomized clinical trial. Laparoscopic adhesiolysis in patients with chronic abdominal pain: a blinded randomised controlled multi-centre trial. Laparoscopic neurolysis of the sacral plexus and the sciatic nerve for extensive endometriosis of the pelvic wall. Decompression and transposition of the pudendal nerve in pudendal neuralgia: a randomized controlled trial and long-term evaluation. The long-term efficacy of sacral neuromodulation in the management of intractable cases of bladder pain syndrome: 14 years of experience in one centre. Sacral neuromodulation as a treatment for neuropathic clitoral pain after abdominal hysterectomy. Is sacral nerve stimulation an effective treatment for chronic idiopathic anal painfi The efficacy and safety of the ganglion impar block in chronic intractable pelvic and/ or perineal pain: A systematic review and meta-analysis. Management of neuropathic pain with methylprednisolone at the site of nerve injury. Adding corticosteroids to the pudendal nerve block for pudendal neuralgia: a randomised, double-blind, controlled trial. This information is publically accessible through the European Association of Urology website. This document was developed with the financial support of the European Association of Urology. Indications: Fever, pain relief Contraindications: Hypersensitivity and use caution in patients with liver disease. Indications: Acute ingested poisonings that were ingested within the last hour Contraindications: Cyanide, mineral acids, caustic alkalis, iron, ethanol, methanol, corrosives, petroleum distillates. Side Effects: dizziness, headache, shortness of breath, hypotension, flushing, palpitations, chest pain, nausea/vomiting Note: Methylxanthine classified stimulants (caffeine & theophylline) usage will antagonize adenosine Albuterol (Proventil) Class: Sympathomimetic, bronchodilator, beta-2 agonist Action: Sympathomimetic that is selective for Beta-2 adrenergic receptors/ Relaxes smooth muscles of the bronchial tree and peripheral vasculature by stimulating adrenergic receptors of sympathetic nervous system. Indications: Asthma, bronchospasms, reversible obstructive airway disease Contraindications: Hypersensitivity, caution with pts with cardiac dysrhythmias Onset/Duration: Onset: 5-8 min Duration: 2-6 hours Dose/Route: Adult/Peds: 2. Dilates peripheral vessels and also inhibits platelet aggregation by blocking the formation of thromboxane A2. Atropine Sulfate Class: Anticholinergic, Parasympatholytic Action: Inhibits actions of acetylcholine (mostly at muscarinic receptor sites) causing decreased salivation and bronchial secretions, increased heart rate and decreased gastric motility. Side Effects: Tachycardia, paradoxical bradycardia if given too slow or too small of dose, mydriasis (dilated pupils), dysrhythmias, headache, nausea/vomiting, headache, dizziness, flushed, anticholinergic effects (dry mouth/nose/skin, blurred vision, urinary retention, constipation) Note: Effects of atropine may be potentiated by antihistamines, procainamide, quinidine, antipsychotics, antidepressants, and thiazides Calcium Chloride Class: Electrolyte, hypertonic solution Action: It is an essential element for regulating the excitation threshold of nerves and muscles, normal cardiac contractility, and blood coagulation. Diphenhydramine (Benadryl) Class: Antihistamine Action: Blocks histamine H receptor sites thereby inhibiting actions of histamine release. Dopamine (Intropin) Class: Sympathomimetic, vasopressor Action: Acts primarily on alpha-1 and beta-1 adrenergic receptors. At low doses (2-5 mcg/kg/min), it may act on dopaminergic receptors causing renal, mesenteric, and cerebral vascular dilation. At moderate doses (5-10 mcg/kg/min), dopamine stimulates mostly beta 1 receptors causing increased cardiac contractility and output. At high doses (10-20 mcg/kg/min) dopamine has mostly alpha-1 stimulation effects causing peripheral arterial and venous constriction. Indications: Hemodynamically significant hypotension in the absence of hypovolemia such as in cardiogenic shock, neurogenic shock, septic shock. The effects this will have on the heart include increased contractile force, increased rate, and increased cardiac output. Indications: Anaphylaxis, cardiac arrest, asthma, bradycardia (first line in peds), shock not caused by hypovolemia, severe hypotension accompanied with bradycardia when pacing and atropine fail. Giving concurrently with alkaline solutions such as sodium bicarbonate will cause crystallization of fluid. Epinephrine, Racemic (Micronefrin) Class: Sympathomimetic Action: Racemic Epinephrine is an inhaled version of epinephrine that is used as a bronchodilator and as an anti-inflammatory to treat laryngeal/tracheal swelling and edema. Its actions are the same as epinephrine but since it is inhaled it has both systemic and localized effects. Indications: Laryngotracheobronchitis (croup), asthma, bronchospasms, laryngeal edema Contraindications: Hypertension, epiglottitis. Onset/Duration: Onset: 5 min Duration: 1-3 hrs Dose/Route: Adult: Not usually given to adults. Side Effects: Tachycardia, hypertension, anxiety, cardiac dysrhythmias, tremors Etomidate (Amidate) Class: Anesthetic, hypnotic Action: Etomidate is a very potent drug that acts on the central nervous system to produce a short-acting anesthesia with amnesic properties. Etomidate has very little effect on respiratory drive which makes it ideal for certain procedures. Indications: Premedication prior to procedures such as endotracheal intubation, synchronized cardioversion, conscious sedation for bone dislocation relocation. Contraindications: Hypersensitivity, labor and delivery Onset/Duration: Onset: < 1 min Duration: 5-10 min Dose/Route: Adult: 0. Side Effects: Respiratory depression, hypotension or hypertension, bradycardia, nausea/vomiting, and rigidity of chest wall muscles Furosemide (Lasix) Class: Loop diuretic Action: Furosemide is a potent diuretic that inhibits the reabsorption of sodium and chloride in the proximal tubule and loop on Henle. Glucagon Class: Pancreatic hormone Action: Glucagon stimulates the liver to breakdown glycogen into glucose resulting in an increase in blood glucose. Glucagon also has a positive inotropic action on the heart even in the presence of beta blockade or calcium channel blockade which makes it useful for beta blocker or calcium channel blocker overdose. Haloperidol (Haldol) Class: Antipsychotic, neuroleptic Action: Blocks dopamine type-2 receptors in the brain thereby altering mood and behavior. Peds: Not recommended Side Effects: Dose-related extrapyramidal reactions, hypotension, nausea/vomiting, blurred vision, drowsiness. Hydroxocobalamin Class: Vitamin, antidote Action: Active form of Vitamin B12 used to treat known or suspected cyanide poisoning. Side Effects: Hypertension, headache, nausea, photophobia, red-colored urine and skin Note: the vial should be repeatedly inverted or rocked, not shaken, for at least 60 sec prior to administration. Contraindications: Hypersensitivity, bleeding disorders, renal failure or disease, active peptic ulcer disease, preterm infants with infection, congenital heart disease from patent ductus arteriosis. Ipratropium (Atrovent) Class: Anticholinergic, bronchodilator Action: Ipratropium blocks interaction of acetylcholine at receptor sites on bronchial smooth muscle resulting in bronchodilation, reduced mucus production, and decreased levels of cyclic guanosine monophosphate. Ketamine (Ketalar) Class: Nonbarbiturate anesthetic Action: Acts on the limbic system and cortex to block afferent transmission of impulses associated with pain perception. Indications: Pain, sedation and sometimes used as an adjunct to nitrous oxide Contraindications: Stroke, hypersensitivity, severe hypertension, cardiac instability. Note: Common street use these days in conjunction with narcotics because they potentiate each other for a longer/higher euphoria. Lidocaine (Xylocaine) Class: Class 1B Antidysrhythmic Action: Lidocaine is a sodium channel blocker that acts primarily on the ventricles of the heart during phase 4 diastolic depolarization which decreases automaticity, suppresses premature ventricular complexes, and raises the V-Fib threshold.

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The first qualifier for body functions and body structures, the performance and capacity qualifiers for activities and 10 2. It acknowledges that every individual can experience a decrement in health and thereby experience some disability. Together, they provide exceptionally broad yet accurate tools to capture the full picture of health. Since the late 1970s, various countries have experimented with the collection of information by lay personnel. These methods, covering a variety of approaches, have evolved in different countries as a means of obtaining information on health status where conventional methods (censuses, surveys, vital or institutional morbidity and mortality statistics) have been found to be inadequate. One of these approaches, so-called community-based information, involves community participation in the definition, collection and use of health related data. The degree of community participation ranges from involvement only in data collection to the design, analysis and utilization of information. Experience in several countries has shown that this approach is more than a theoretical framework. The main criteria for selection of this name were that it should be specific (applicable to one and only one disease), unambiguous, as self-descriptive and simple as possible, and based on cause, wherever feasible. However, many widely used names that did not fully meet the above criteria were retained as synonyms, provided they are not inappropriate, misleading or contrary to the recommendations of international specialist organizations. Eponymous terms are avoided, since they are not self-descriptive; however, many of these names are in such widespread use. Hodgkin disease, Parkinson disease and Addison disease) that they must be retained. Each disease or syndrome for which a name is recommended is defined as unambiguously and as briefly as possible. These comprehensive lists are supplemented, if necessary, by explanations about why certain synonyms have been rejected or why an alleged synonym is not a true synonym. The differences between a nomenclature and a classification are discussed in Section 2. Unnecessary duplication will thus be avoided, by a coordinated approach to the development of the various components of the family. Several classifications may, therefore, be used with advantage; and the physician, the pathologist, or the jurist, each from his own point of view, may legitimately classify the diseases and the causes of death in the way that he thinks best adapted to facilitate his inquiries, and to yield general results. A statistical classification of diseases must be confined to a limited number of mutually exclusive categories that are able to encompass the whole range of morbid conditions. The categories have to be chosen to facilitate the statistical study of disease phenomena. A specific disease entity that is of particular public health importance, or that occurs frequently, should have its own category. Every disease or morbid condition must have a well-defined place in the list of categories. Consequently, throughout the classification, there will be residual categories for other and miscellaneous conditions that cannot be allocated to the more specific categories. It is the element of grouping that distinguishes a statistical classification from a nomenclature, which must have a separate title for each known morbid condition. The concepts of classification and nomenclature are, nevertheless, closely related because a nomenclature is often arranged systematically. A statistical classification can allow for different levels of detail if it has a hierarchical structure with subdivisions. A statistical classification of diseases should retain the ability both to identify specific disease entities and to allow statistical presentation of data for broader groups, to enable useful and understandable information to be obtained. The structure has developed out of that proposed by William Farr in the early days of international discussions on classification structure. It has stood the test of time and, though in some ways arbitrary, is still regarded as a more useful structure for general epidemiological purposes than any of the alternatives tested. In place of the purely numeric coding system of previous revisions, the 10th revision uses an alphanumeric code with a letter in the first position and a number in the second, third and fourth positions. The Tabular list, giving the full detail of the four-character level, is divided into 22 chapters. The definitions in Volume 1 have been adopted by the World Health Assembly and are included to facilitate the international comparability of data. Each chapter contains sufficient three-character categories to cover its content; not all available codes are used, allowing space for future revision and expansion. The remaining chapters complete the range of subject matter currently included in diagnostic data. The four-character subcategories are used in whatever way is most appropriate, identifying, for example, different sites or varieties if the three-character category is for a single disease, or individual diseases if the three-character category is for a group of conditions. When the same fourth-character subdivisions apply to a range of three character categories, they are listed once only, at the start of the range. A note at each of the relevant categories indicates where the details are to be found. It indicates the categories into which diagnoses are to be allocated, facilitating their sorting and counting for statistical purposes. It also provides those using statistics with a definition of the content of the categories, subcategories and tabulation list items they may find included in statistical tables. Although it is theoretically possible for a coder to arrive at the correct code by the use of Volume 1 alone, this would be time-consuming and could lead to errors in assignment. An Alphabetical index, as a guide to the classification, is contained in Volume 3. The introduction to the index provides important information about its relationship with Volume 1. The rules for this selection in relation to mortality and morbidity are contained in Section 4 of this volume. The lists of inclusion terms are by no means exhaustive and alternative names of diagnostic entities are included in the Alphabetical index, which should be referred to first when coding a given diagnostic statement. This usually occurs when the inclusion terms are elaborating lists of sites or pharmaceutical products, where appropriate words from the title.

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The areas covered include the technical language used in diagnosis, patient care, surgery, pathology, general practice, pharmacy, dentistry and other specialisations, as well as anatomical and physiological terms. Informal, everyday and sometimes euphemistic terms commonly used by people in discussing their condition with healthcare professionals are also included, as are common words used in reading or writing reports, articles or guidelines. The dictionary is designed for anyone who needs to check the meaning or pronunciation of medical terms, but especially for those working in health-related areas who may not be healthcare professionals or for whom English is an additional language. Very many people have helped or advised on the compilation and checking of the dictionary in its various editions. In particular, thanks are due to Dr Judith Harvey for her helpful comments and advice on this fourth edition and to Dr Marie Condon for some revisions and clarification. Also to Lesley Bennun, Lesley Brown and Margaret Baker who copy-edited the text and Dinah Jackson who revised the pronunciations. Pronunciation Guide the following symbols have been used to show the pronunciation of the main words in the dictionary. Note that these are only guides, as the stress of the word changes according to its position in the sentence. Compare adduct who performs an illegal abortion abduction abortion pill abduction / b d"kfifin/ noun the movement abortion pill /fi bfi fi(fi)n pfil/ noun a drug of a part of the body away from the centre line that causes an abortion to occur very early in of the body or away from a neighbouring part. A chronic abscess is usually treated pregnancy, or a procedure which causes this to with drugs. Three peo put on wounds ple were killed in the accident on the motor absorption way. Abbr A & E accident form time, especially not eating or drinking absti accident form / ksfid(fi)nt ffi m/, accident nence from alcohol report form / ksfid(fi)nt rfi pfi t ffi m/ noun a abulia form to be filled in with details of an accident abulia /fi bu lifi/ noun a lack of willpower accident prevention abuse accident prevention / ksfid(fi)nt prfi abuse noun /fi bju s/ 1. Also called wrongly Heroin and cocaine are drugs casualty ward accommodation which are commonly abused. It is a post-ganglionic nerve junctions, and nicotinic, feature of untreated severe diabetes. These blackheads achlorhydria achlorhydria / efiklfi hafidrifi/ noun a condi often then become infected. She is using a tion in which the gastric juices do not contain cream to clear up her acne. It is used in the treatment medicinal effect active immunity of rhinitis, urticaria and eczema. Also called activities of daily living / k tfivfitiz fiv erythroedema, pink disease defili lfivfifi/ noun a scale used by geriatricians acromegaly and occupational therapists to assess the ca acromegaly / krfifi me&fili/ noun a disease pacity of elderly or disabled people to live in caused by excessive quantities of growth hor dependently. The bed losses forced one hospital to adapt send acutely ill patients to hospitals up to sixteen adapt /fi d pt/ verb 1. Treatment is with corticosteroid injec have escaped into the pancreas, causing symp tions. Compare abducent 7 adiposuria adduct adenomyoma adduct /fi d"kt/ verb (of a muscle) to pull a adenomyoma / dfinfifimafi fifimfi/ noun a leg or arm towards the central line of the body, benign tumour made up of glands and muscle or to pull a toe or finger towards the central adenopathy adenopathy / dfi nfipfifii/ noun a disease of line of a leg or arm. Opposite abduct a gland adducted adenosclerosis adducted /fi d"ktfid/ adjective referring to a adenosclerosis / dfinfifisklfi rfifisfis/ noun body part brought towards the middle of the the hardening of a gland body adenosine adduction adenosine /fi denfifisi n/ noun a drug used adduction /fi d"kfifin/ noun the movement of to treat an irregular heartbeat a part of the body towards the midline or to adenosine diphosphate wards a neighbouring part. Opposite abductor trafi ffisfefit/ noun a chemical which occurs in aden all cells, but mainly in muscle, where it forms aden / dfin/ prefix same as adeno (used be the energy reserve. Also called er, which makes the organ less able to perform pharyngeal tonsils its proper function. Also called fatty degener adenoid vegetation ation adenoid vegetation / dfinfifid ved fi adipose tissue tefifi(fi)n/ noun a condition in children where adipose tissue / dfipfifis tfifiu / noun a tis the adenoidal tissue is covered with growths sue where the cells contain fat adiposis and can block the nasal passages or the Eus adiposis / dfi pfifisfis/ noun a state where tachian tubes too much fat is accumulated in the body adenolymphoma adiposis dolorosa adenolymphoma / dfinfifilfim ffifimfi/ adiposis dolorosa /dfi pfifisfis dfilfi noun a benign tumour of the salivary glands rfifisfi/ noun a disease of middle-aged women adenoma in which painful lumps of fatty substance form adenoma / dfi nfifimfi/ noun a benign tu mour of a gland in the body. Also called adrenal body, ad a drug to enhance the effect of the main ingre renal. It is administered admission /fid mfifi(fi)n/ noun the act of be as an emergency treatment of acute anaphy ing registered as a hospital patient laxis and in cardiopulmonary resuscitation. Alpha receptors constrict the bronchi, beta 1 receptors speed up the heart adult beat and beta 2 receptors dilate the bronchi. Opposite efferent tion without your help afferent nerve afferent nerve noun same as sensory nerve adynamic ileus afferent vessel adynamic ileus /efi dafin mfik filifis/ noun afferent vessel / f(fi)rfint ves(fi)l/ noun a same as paralytic ileus tube which brings lymph to a gland aegophony affinity aegophony /i &fiffini/ noun a high sound of affinity /fi ffinfiti/ noun an attraction between the voice heard through a stethoscope, where two substances there is fluid in the pleural cavity aflatoxin aer aflatoxin / flfi tfiksfin/ noun a poison pro aer /efi/ prefix same as aero (used before vow duced by some moulds in some crops such as els) peanuts African trypanosomiasis 10 African trypanosomiasis African trypanosomiasis / frfikfin happen the disease develops through the trfipfinfifisfifi mafifisfis/ noun same as sleep agency of bacteria present in the bloodstream. Aftercare agenesis /efi d enfisfis/ noun the absence of treatment involves changing dressings and an organ, resulting from a failure in embryonic helping people to look after themselves again. Bones about or twitching nervously because of worry become more brittle and skin becomes less or another psychological state the person elastic. The most important changes affect the became agitated and had to be given a seda blood vessels which are less elastic, making tive. This also reduces the agitation supply of blood to the brain, which in turn re agitation / d fi tefifi(fi)n/ noun a state of be duces the mental faculties. He breathed the pol She suffered the agony of waiting for weeks luted air into his lungs. It is obstruction spread mostly by sexual intercourse and can airway obstruction affect anyone. It is also transmitted through in airway obstruction / efiwefi fib str"kfi(fi)n/ fected blood and plasma transfusions, noun something which blocks the air passages akathisia through using unsterilised needles for injec akathisia / efikfi fifisifi/ noun restlessness tions, and can be passed from a mother to a akinesia akinesia / efikfi ni zifi/ noun a lack of volun fetus. Alcohol is a de who takes an intelligent interest in his or her pressant, not a stimulant, and affects the way surroundings the patient is still alert, the brain works. Allergic reaction to serum noun a tube in the body going from the mouth is known as anaphylaxis. Treatment of aller to the anus and including the throat, stomach gies depends on correctly identifying the aller and intestine, through which food passes and gen to which the patient is sensitive. This is is digested done by patch tests in which drops of different alimentary system allergens are placed on scratches in the skin. Note also that live can be used in allergic agent front of a noun: the person was injected with live allergic agent /fi l! Alkaline solu tions are used to counteract the effects of acid which cause a physical reaction such as sneez poisoning and also of bee stings. If strong al ing or a rash in someone who comes into con kali, such as ammonia, is swallowed, the pa tact with them She has an allergy to house tient should drink water and an acid such as hold dust. You have an allergy or you are allergic to alkaloid alkaloid / lkfilfifid/ noun one of many poi something. Compare lessness, fatigue, nausea and swelling of the homeopathy face, hands and feet. The chemical all or none law /fi l fi n"n lfi / noun the rule that the heart muscle either contracts fully symbol is Al. Compare hypotrichosis alveolar / lvfi fifilfi, l vi filfi/ adjective re alopecia areata ferring to the alveoli alopecia areata / lfifi pi fifi ri efitfi/ noun alveolar bone a condition in which the hair falls out in patch alveolar bone / lvfi fifilfi bfifin/ noun part es of the jawbone to which the teeth are attached alpha alveolar duct alpha / lffi/ noun the first letter of the Greek alveolar duct / lvfi fifilfi d"kt/ noun a duct alphabet in the lung which leads from the respiratory alpha-adrenoceptor antagonist alpha-adrenoceptor antagonist / lffi fi bronchioles to the alveoli. Also called alpha blocker alveolitis alpha cell alveolitis / lvifi lafitfis/ noun inflammation alpha cell / lffi sel/ noun a type of cell of an alveolus in the lungs or the socket of a found in the islets of Langerhans, in the pan tooth creas, which produces glucagon, a hormone alveolus that raises the level of glucose in the blood. Risk factors include age, genes, makes blood vessels wider, used to treat impo head injury, lifestyle and environment. Compare emmetropia ambidextrous amfetamine ambidextrous / mbfi dekstrfis/ adjective amfetamine / m fetfimi n/ noun an addic referring to a person who can use both hands tive drug, similar to adrenaline, used to give a equally well and who is not right or left-hand feeling of wellbeing and wakefulness.

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However, not all practices employ this strategy as the practitioner may prefer to take the picture themselves in case, for example, the patient has small pupils and a clear image is difficult or if there is a specific pathology that they wish to ensure is captured clearly. Cataract co management schemes are popular with patients as they benefit from fewer appointments and more convenient post-operative care, and research has shown that patients are more satisfied with optometrist rather than hospital post-op appointments (Warburton, 2000). These patients will all require some form of 114 refractive correction (even if only a basic pair of reading spectacles) so the practice will benefit from extra income from dispenses as well as satisfied patients who are more likely to return in the future. Specialist contact lens fitting may be popular as it provides a challenge to the practitioner over standard soft contact lens fitting where lenses only have a choice of one or two base curves. It may be funded by contact lens exam fees and from the profit made on contact lenses if the patient purchases them from the practice. Contact lens patients form long-term relationships with the practice and make regular purchases, with research showing they are more profitable than spectacle wearers (Ritson, 2006). It is possible the popularity of specialities may change over the next few years if level 2 therapeutics prescribing becomes more widely taken up; currently there are only 70 optometrists with an independent or supplementary qualification (Courtenay et al, 2011). The amount charged for specialist services showed a significant decrease (Mann Whitney U, p=0. As well as the increasing prevalence of fundus cameras, as mentioned above, economic conditions may have been a factor in this. Practices may use supplementary tests such as fundus photography as a loss making marketing tool to attract customers into the practice with the aim to subsidise this with dispensing revenue. Single independent practices had the highest charges in both surveys, 115 their customers are often willing to pay more for personal attention, and the increased range of charges (fi125 compared to fi55) in 2010 suggests that some are positioning themselves at the higher end of the market as a point of differentiation. Overall, the amounts charged by independent practices reduced significantly between the surveys showing that all types of practices have been affected by increased competition and economic conditions. Behavioural optometry had the highest average charge in both surveys; it was also one of the least popular specialities. This may allow practices to charge higher fees as patients are prepared to travel further and pay extra to consult practitioners with a reputation for services such as dyslexia testing. The survey of 300 optical practitioners (optometrists and dispensing opticians) involved a smaller sample than this study and may have been biased as the population was limited to the readership of Optician magazine. The Optician survey found some results were very similar to those of the 2010 questionnaire in this study, such as the prevalence of pachymeters (13% and 12. However, some results found differences, for example the Optician survey found 66% of respondents had fundus cameras, whilst this study found this to be 73. Both parts of this study were conducted in July and August, and this may have had an effect on what equipment respondents were looking to buy in the forthcoming six months. An explanation for this may be that practitioners were waiting for Optrafair in order to compare different instruments and take advantage of any discount that manufacturers may offer at the trade fair. Fundus cameras were still the most popular instruments that practitioners were looking to buy in the 2010 survey, however, as around three-quarters of practices now have this technology, the market for new purchasers is beginning to plateau. A challenge to the industry is that the amount practices charge for specialist services showed a significant reduction between the surveys. This trend does not bode well for optometrists as market data also showed falling sales of spectacles and sunglasses over 2009 and 2010 (Lamouroux, 2011) however the same market research shows a 5% growth in the contact lens market in 2010. Practitioners will need to consider these challenges when investing in new instrumentation to ensure they have a sustainable long-term funding model either from charges to patients or income from co-management schemes. This study focuses on optometrists in the East and West Midlands, however patient attitudes and demographics vary greatly across the country as does devolved health policy in Scotland and Wales. This means that different results could be obtained if extending the study to other areas. If they have previously used a similar piece of equipment, a quick read of the manual may be sufficient but in cases of new technology the instrument supplier would be expected to provide training. The main disadvantages of this is that if a number of staff need to be trained they must all be present on the day of training and be exempt from other duties during the training, furthermore the costs for the instrumentation company can be increased if the trainer is required to travel a large distance. Training will usually take place during working hours, thus the practitioner may be required to cancel appointments, which will have a financial implication. Other disadvantages are that the training may be complicated and difficult to digest in one training session, and staffing may change, requiring further training and associated costs. It goes without saying that if optometrists are to take part in advanced screening and shared care management of patients they must be competent in the use of relevant instrumentation and technology required for that task. Research has shown that the majority of undergraduate optometry students were balanced learners who responded to a mixture of learning styles (Prajapati et al, 2011). Surveys of health workers based in rural Australia also found that lack of local availability was the biggest barrier to completing continuing education (Keane et al, 2011) and that good access to professional development training had a positive effect on job satisfaction and career aspirations (Buykx et al, 2010). Practitioners have expressed that lack of time and cost of training are principle barriers to taking part in extended training courses, such as therapeutics prescribing (Needle et al, 2008). Distance learning allows the practitioner to learn at their own rate and reduces the costs of travel and time taken out of practice to attend training at universities or other venues. Hamam (2004) explored distance learning for laser surgery and discussed the advantages and disadvantages. Advantages include the ability for the learner to go at their own pace, reaching those unable to travel and that large numbers of learners can be taught. Disadvantages can include less 121 human interaction, users feeling isolated in their learning, fear of technology and the risk that the learner may be a passive rather than an active participant. A previous study compared training methods used to educate optometrists about patients with intellectual disabilities (Adler et al, 2005). The study found that those who received lectures followed by hands-on training with patients were significantly more confident in their abilities than those who received lectures only. This study, however, did not look at each method separately therefore those who received both methods of training had benefited from more hours of training as well as different methods. The study used only subjective methods of assessment and acknowledged that using an objective measure of ability would be preferable. The aim of this study was to compare different methods of training on new instrumentation. As well as comparing the methods individually, the order in which several training methods are given was investigated to determine which was the most effective. As some participants had a refractive error whilst others were emmetropic, prescriptive lenses were attached to the back of the viewing apertures to simulate a refractive error. These were selected at random and changed between training sessions so that subjects would not test the same prescriptive lens twice. In all three training sessions the participants were allowed 30 minutes in which to refract one eye using the phoropter. This training was based on training that would normally be delivered to a new user in a practice environment but tailored to the needs of each trainee depending on their performance and any questions they asked. The computer based training presentation was 10 minutes in duration; the participant was instructed that they could play, pause and review the presentation as necessary throughout a 30 minutes session. In the third training session the participants received no assistance from either the computer presentation nor from 124 the trainer, and were only allowed to read the manual provided with the phoropter to familiarise themselves with the instrument. The effectiveness of the each method of training was measured objectively and subjectively. Rae, in his book on measuring training effectiveness, recommends subjective evaluation and also asking the trainee to rate how effective they think they are in a number of aspects that will be covered by the training (Rae, 1991).

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Enzymes especially are impeded in their activity by increasing environmental stress. Due to the deficiency of enzyme function a backup of metabolites present before the respective enzymatic reaction occurs as well as a lack of substrates to be metabolized after this reaction. The administration of the corresponding catalysts in homoeopathic preparations is based upon the concept that the metabolic process is activated and that blocked cell or enzyme functions are reactivated. Since enzyme damage expresses itself as chronic and/or degenerative diseases, the application of catalysts is therefore primarily indicated for such diseases. Catalysts are substances which accelerate the equilibration of chemical reactions without disturbing the balance of the process themselves. An increase of the reaction speed by six decimal powers is not uncommon, since one single enzyme molecule is often capable of converting more than 10,000 substrate molecules per second. At the end of a reaction the catalyst remains unchanged and is again available to immediately catalyse the same reaction on the next molecule. It is a basic, closed, reaction path present in humans, animals, and plants; the cleavage products of the carbohydrate metabolism, the oxidative carbohydrate metabolism, the oxidative decomposition of fatty acids and after transamination the cleavage products from the protein metabolism as well all end in it. In conjunction with the respiratory chain the citric acid cycle is simultaneously the most significant source of energy for the metabolic process. It supplies the hydrogen for the biological oxidation and is thus closely linked to the energy metabolism of the cells. The transformation of one carboxylic acid into the next within the citric acid cycle is mediated by enzymes. This can in turn trigger reactions or blockades with consecutive symptoms or disease manifestations in various tissues. It must be taken into consideration that catalysts can only act when the milieu is correct. Some catalysts have to be activated first by these co-factors to render them functionable. The available preparations may be classified into three groups: Group A: Acids of the citric-acid cycle and their salts. Group B: Quinones and their derivatives as well as other intermediary respiratory catalysts. Group C: Compounds which effect stimulation: biogenic amines, hormones, elements (cerium), botanical extracts (anthocyanins). General recommendations the implementation of bio-catalysts has a strong stimulative effect on patients. It is recommended to drink at least 2 to 3 liters during the first three days of treatment and to extense refrain from physical activities as well. Signs of a regressive vicariation should not be suppressed but rather excreted through the assistance of biological therapeutic remedies. This phenomenon occurs when the body is in an extremely unstable condition or is too weak to be subjected to a stimulation therapy. It must be particularly ensured with patients in a weakened condition that the treatment is very slowly commenced and is not applied with massive doses of remedies. Example: Begin with 1/2 ampoule orally 2x weekly or 2x weekly dissolve 1 ampoule in 1 1/2 liters of water and drink this solution in small sips throughout the day. The bio catalysts frequently achieve the desired effect without the occurrence of severe healing crises. For all catalyst preparations of Group B, a repetition of injections should only be conducted after subsidence of the possible occurrence of initial aggravation and always when complaints recur. Furthermore, a proper drainage is important, that is, for patients with severe toxic affliction, the endogenic defence system should be mobilized before the therapy with catalysts. Stabilization of the disease process, that is, treatment of possible inflammatory processes, whereby, in certain cases, the conventional therapy may not be dis continued immediately. A stabilization can be achieved through a diet, sensible life style, sufficient exercise, support of the endogenic defence system, etc. Supplementation of deficient substances, including vitamins and trace elements, as well as the treatment of present dysbiosis. A weakened organism with severe deficiencies and dysbiosis must be treated first with parenteral vitamin pre parations. With regard to mineral and trace elements, particularly zinc, calcium, potassium, and magnesium are important. Functional disorders can be generated in the material or dynamic area; the consequences are always reciprocal. The following constellations result there from: a) the initial substrate is quantitatively insufficient or qualitatively altered. Based on the Michaelis Menten relation of the dependency of the catalytic reaction on the available substrate, a dysregulation is given at the initial step. The product to be catalysed is either insufficiently or not formed at all the metabolic process chain is weakened or interrupted. The cited performance of the chain is always determined by the weakest link substrate, enzyme, or intermediary product. Due to the situation that, after every enzymatic dysfunction, the subsequent product to be catalysed is no longer sufficiently formed, the intermediary products play an essential role in the further course of the chain reaction. Therefore, during therapy, enzymatic defects should not only be affected with the lacking or deficient enzyme when at all possible but should also be specifically treated with the intermediary products behind the enzyme obstruction. Several enzyme reactions require magnesium or manganese ions as additional activators. Thus, all kinase reactions require magnesium ions for the phosphate transfer, whereas alkaline phosphatases are activated by magnesium and manganese ions and peptidases by manganese. In many cases the magnesium ions can be replaced by manganese ions when necessary. Thus, it makes sense and is understandable that specific therapy with the intermediary catalysts of the citric acid cycle is initiated or combined with an injection of magnesium and manganese ions as phosphate compounds due to the significance of the anorganic phosphate. Fields of application All diseases classified as cellular phases (degeneration phases, dedifferentiation phases) and which are consequently characterized by defective enzymatic control, blockages and/or defective cellular oxidation. It is advisable in such therapy to inject two to three acids (and/or their salts) simultaneously in the form of a combination injection. As magnesium and manganese ions activate a number of enzymatic processes the kinase reactions in particular, during which phosphate transfer occurs (see subsection 3. During this period, however, the indicated anti-homotoxic preparations (Injeels, Homaccords, and other Heel combination preparations, as well as suis-organ preparations and nosodes) are to be applied. Indeed these may also be employed in conjunction with the acids/salts of the citric acid cycle even during the injection period. During the intake of a homoeopathic remedy present symptoms may be temporarily aggravated (initial aggravation). Each acid and/or its salt may be injected separately and repetitively in the Injeel-forte form as well. This is indicated primarily when a particularly effective action during one of the combined injections listed above (1 to 4) was achieved. The ampoules contained in this combination should subsequently be applied individually. The diet should include ample fresh fruit, grape juice, bilberries, and beet root. The latter are rich in anthocyanins (activators of cellular respiration, hydrogen acceptors); also refer to intermediary catalysts, Group C: Myrtillus, Beta vulgaris rubra! Citric-Acid-Cycle combination pack (contains 9 ampoules of single constituent Injeels + 1 ampoule Magnesium Manganum-phosphoricum-Injeel). List of group A catalysts the Injeel preparations contain the following potency chord in all preparations: D10, D30, D200 0,367 ml each.

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Hold the skin taut and begin the treatment in the middle of the forehead just above the nose. Run the handpiece along the forehead and above the eyebrow, stopping at the temple. Lift the handpiece and return to the area where you started the procedure (ask the patient if they are comfortable. Next, continue with the upper lip area, the chin and any remaining areas on the side of the face. Run the handpiece in an upward motion, then pull and lift outward toward the ears. Be sure to work the Vermilion Border, reducing fne lines and leaving the lips refreshed and full. This will also further stimulate blood fow, leaving the patient with a healthy, beautiful glow. Massage a small amount of Intensive Moisturizer Plus into the face and neck (if patient is acne prone, skip this step). If using one of the Disposable Crystal-Free Nozzles, please dispose of according to local, state and federal guidelines. After the initial 6 treatments, a typical patient returns on a monthly basis for maintenance. Unlike acid peels that can cause hyperpigmentation on darker skin, microdermabra sion is safe for all skin types. A series of treatments will actually beneft acne more than the use of topical products. Cystic acne should be treated with an oral or topical antibiotic prior to beginning microdermabra sion treatments. If the condition is calm, the patient can be treated at the request of the physician. This procedure is excellent for patients with ingrown hairs and for patients undergoing hair removal treatments. Use of the Gio Peel System is at the sole risk of the operator and is intended for and limited to use only by or under the close direct supervision of a trained certifed medical professional. Depth of Abrasion Skin Reaction Operator Level Epidermis Coenocytes Layers Redness; No Bleeding Esthetic Level Malpighian Layers Suffusion; Moist Medical Level Basal Layers Blood Specs Medical Level Epidermal/Dermal Layers Bleeding Medical Level Indications for Use All of the Gio Pelle models improve skin texture through progressive operator controlled mechanical exfoliation of the skin. Assessment of the problem and current skin condition should be followed by a treatment plan. After determining that microdermabrasion is the treatment of choice, a test area should be done on the back of the hand to demonstrate the sensation prior to applying treatment to the face or other areas. Treatments range from 4 weekly treatments for normal skin to as many as 12 or more for scars. The derma enhancing treatment is performed consecutively 7-10 days between treatments. A major beneft of a mechanical abrasion treatment is that it is fast, predictable, painless and effective. Some advantages to the patient are having no downtime from work or social activities with a rapid recovery time in as little as 6 to 8 hours depending on depth of treatment. Exfoliation Rate the rate at which tissue is removed is directly related to the speed and volume at which the crystal passes through the nozzle. Double Check the Gio Peel and the Nozzle Connections Check that the Gio Peel is in proper working order and has a new clean nozzle that has been properly installed onto the tubing. People with more sensitive skin may require lower vacuum levels with longer, lighter treatments and more treatment sessions. Begin the treatment by gently moving the nozzle over the treatment area in an up and down pattern. Cover the area completely in one direction then go over the same area in the opposite direction. It is used in one direc Linear Pattern tion, then the opposite direction to work on wrinkles, skin folds, superfcial scars and stretch marks. This can be used for large areas with uneven skin Square Pattern texture, enlarged pores, superficial acne scars, blackheads and comedones. Post Treatment Recommendations Some patients may experience a minor temporary reddening of the skin similar to a mild sunburn or windburn. This should be Pressure for Face Pressure for Eye & Neck Area performed in short, quick strokes to insure patient comfort. Be sure to work the Vermilion Border, reducing fne 25 5 25 5 lines and leaving the lips refreshed and full. It is recommended that you have a least one spare flter so you do not experience down time because of flter wetness or unforeseen flter damage. Filter Replacement Even with routine washing, overtime the flter will become clogged with waste materials which block off vacuum pressure. When this occurs a decrease in performance will be noticed resulting in less effective treatments. O-Ring Replacement Overtime the o-rings on the Vacuum Post and the Filter Canister Cover may become damaged or warn and need to be replaced. Using our six-step procedure and asking yourself a logical series of questions allows most problems to become self evident. Once the nature of the problem is discovered, deciding how to resolve it becomes easier. If the tubing is loose, cut the tubing and reattach renewed hose end to the ftting. Carefully insert the straightened end of a small paper clip out of the nozzle into the nozzle tip to clear. Please make an attempt to follow the section on troubleshooting before calling to order parts. Writing down the information derived from using these test procedures will assist us in providing quicker and more accurate assistance. We honor most major national holidays and our facility will be closed every Thanksgiving, Christmas and New Years day.

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Of the fruits that may be treated by this method, the following compound, a valuable tonic laxative, is given as typical: Expressed Fluid Extract Bromelia Compound. The pineapples are previously cut in thin slices and covered with the sugar, standing closely covered, while digesting the drugs. Incorporate the pineapple with the drugs while hot" as they are transferred to the centrifuge or drug-press, and obtain the fluid, which should, by the addition of boiling water in the press or centrifuge, be made to measure one gallon of finished fluid extract. Vehicles or solvents are preparations of water, sugar and alcohol, intended to take up and hold in solution soluble inorganic substances, to act as adjuvants aiding the therapeutic efficiency of medicinal combinations, and to disguise and render palatable unpleasant agents. These we divide into simple elixirs, being the plain combination of alcohol, water and sugar; aromatic elixirs, or the addition of aromatic flavouring to a simple elixir; and adjuvants, or accessory elixirs, containing substances that aid the therapeutic action of other agents. Medicinal Elixirs are those which contain the medicinal properties, in definite therapeutic. I 1/2 Mix the water, alcohol and glycerin together and dissolve the sugar in it, reserving 6 ounces of sugar; pour over the orange peel in a macerating vessel and macerate three days; displace with centrifuge or percolator, using hot water to obtain 4 3/4 pints. Triturate the oil of orange with the 6 ounces reserved sugar, and dissolve in the percolate, by first rubbing in the mortal, by small additions 6 or 8 ounces of the fluid. This is an excellent adjunct to combinations for coughs, colds, and for pulmonary compounds. These considerations have heretofore prevented an official recognition of elixirs. Owing to their extensive use by practitioners all over the country, it becomes necessary to notice some of the most important in this commentary. But, owing to the extensive preference by the profession all over the country for this valuable product-medicinal elixirs-the U. Dispensatory is compelled to give them notice, but pushes them off in the smallest type in an inconspicuous place, because, forsooth, they have not yet received that mystic stamp "Official. From the Physio-Medical standpoint, as explained in the beginning of this work, we learn that medicinal strength, or more properly speaking therapeutic utility, does not mean concentrated pharmaceutical products. Not to mention the baleful influence of alcohol in the highly alcoholic preparations, even a sanative agent in a highly concentrated form will, especially if its administration be long continued, expend its influence so locally upon the peripheral nerves of the mucous structures of the digestive tract, as to excite violent resistive and repulsive efforts, obstructing its assimilation and broader therapeutic influence, the agent being rejected by the Vital Force, and the physician is thwarted, although his selection of the agent were highly proper. Remembering these facts we realize the value of a fluid preparation affording the broad constituency of the drug in normal proportions, with as much palatableness and elegance as is consistent with these essential therapeutic requirements. This should measure 4 pints of the finished elixir; if therefore, after adding the sugar it is not enough, more percolate may be added. All fluid compounds such as the so called" Compound Syrup of Stillingia," Compound Syrup of Mit. We submit the following combinations, so popular with the Physio-Medical profession, made on the standard strength of l lb. After displacement ceases pour on boiling water, set aside the first 20 pints of fluid, continue the displacement with boiling water as menstruum till 12 pints and 10 ounces are obtained in which dissolve the sugar and add to the first percolate, strain through white flannel. The following formula we have used for a number of years, and have found it reliable in all scrofulous, and syphilitic troubles. Mix ten pints of water with the alcohol and pour over the mixed drugs in a macerating vessel, let stand for 8 or 10 days mixing frequently, transfer to the centrifuge or percolator, treat with boiling water, set aside the first 20 pints, continue till 12 pints more have passed, in which dissolve the sugar, add to it more percolate if necessary to make 5 gallon; when the first percolate is added, then strain through flannel. There seems to be no definite standard of strength, or formula for this most valuable and popular compound, like many other of our compounds; and it seems that Physio-Medicalists must wait till the U. If the oil of peppermint is used, it is to be poured in the absorbent cotton that is placed in the funnel end of the percolator, rubbing, picking, and triturating the oil through it thoroughly. The Physio-Medical Dispensatory, page 661, gives the following formulae for Syrup Rhubarb and Potassa, Neutralizing Cordial. Rhubarb, well crushed, four ounces: dried peppermint herb eight ounces (or the green herb four ounces); golden seal and cinnamon, each, one ounce. Macerate for two days with one quart of brandy, or with the same quantity of 40 per cent. Transfer to a percolator, treat with water and set aside the first pint and a half. Continue the process with water until three quarts have passed, express the dregs, add four pounds of sugar and dissolve at a gentle heat, evaporating until the addition of the first liquid shall make a gallon. When cold, mix the liquors and add one ounce and a half of bicarbonate (not carbonate) of potassa. The addition of the alkali turns the whole syrup deep red; and occasions a flocculent precipitate to remove which the whole may afterwards be filtered through flannel; though in practice this. Hill, which has 2 ounces each of rhubarb and carbonate of potassa; one ounce each of golden seal and cinnamon to a gallon of brandy, four pounds of sugar, and twenty drops oil of peppermint. There is too little rhubarb in both these formulas, and the large amount of spirits in both, especially brandy, when we remember that this preparation is largely used for stomach and intestinal troubles of children, is most objectionable. Besides the process of treatment particularly the first formula is laborious and yields an inelegant product. This standardization of our Physio-Medical agents and compounds, into medicinal elixirs, with two pounds of the crude ground drugs to the fluid gallon of finished elixir, will, we feel confident, meet the approbation of the general profession. This gives a preparation of ample strength for ordinary purposes; for extra cases the dose can be increased, or they can be made of double strength, and get the same proportionate standard maintained. These elixirs are especially adapted to the treatment of chronic cases requiring long continued administration, as they will be tolerated locally by the mucous membrane without unpleasant local effects. The object of simple syrups, like that of simple elixirs, is that of a vehicle, solvent, preservative" and to disguise the unpleasant taste of medicines. They are also used as excipients, forming the mass and consistency of pills, suppositories, etc. A medicinal syrup, we shall define to be, a fluid preparation in which large quantities of sugar have been added as a preservative to a decoction, which when finished. This establishes sufficient practical difference pharmaceutically and therapeutically, between Medicinal Syrups and Elixirs; and also we have a definite standard strength medicinally established on a therapeutical basis, instead of the now solely pharmaceutical standpoint, of heretofore vague and indefinite "shot gun" combinations and mongrel pharmaceutical products. Simple syrups may be divided into two kinds, the plain or simple syrup and the aromatic Syrup. There is much variation among pharmacists as to the quantity of sugar, and method of preparing simple syrups, But the most lamentable fact is that the druggists, a very large per cent. Unblushingly, they appropriate prescriptions of their physician patrons, and they become famous prescribers, donning the appelation of " Doctor," they gravely undertake to prescribe for the most serious and complicated diseases. They are geniuses of marvellous" headache powders," " specifics," for gonorrhoea, syphilis, "liver syrups," "antigermicides," and many" magic discoveries. Cold percolation or any other "cold method" of making syrups is unaseptic, unsanitary and unsafe; and all physicians who have the good of their clientele at heart, cannot be too severe in the condemnation of such methods, and druggists. None but distilled water should be used in making simple and aromatic syrups, and this should always be heated to not less than 212 deg. Of course in the medicinal syrups, distilled water is the best, for being devoid of nearly all the inorganic constituents, it will take up and hold in solution more of the medicinal constituents. However, not being easily obtained in so large quantities as is necessary often in making most medicinal syrups, the continued boiling that is necessary removes nearly all the lime-salts of hard water, renders the process objectionable from a sanitary standpoint. But when distilled water is not obtainable, good filtered rain water is the next best, lastly well or hydrant water. As to the quantity and quality of sugar, we prefer granulated sugar, of the fine grade, because granulated sugar will be of more uniform dryness, an important point in obtaining accuracy of measurement, for one must know the exact increase of fluid bulk on the addition of the sugar. As a rule, with regard to consistency of syrup, one and one half parts of sugar to one of water is the minimum, and two parts of sugar to one of water the maximum. The following formula gives the fluid increase on the addition of granulated sugar to distilled water at a temperature of 212 deg. The pharmaceutical object is to obtain a syrup of sufficient consistency to keep well. Of course it is necessary often, for special purposes, to have a syrup of greater or less consistency. This makes an excellent syrup for soda fountains, any of the flavourings or fruit extracts mix readily with it. Aromatic Syrups:-These are used for the same purpose as the plain or simple syrup, but are better as solvents and vehicles for the inorganic agents, such as alkalies. If after cooling, some oil globules appear on the surface of the syrup remove with blotting paper, or little pledgets of absorbent cotton, After the syrup has stopped dropping, a very light flavouring elixir may be obtained by percolating through the cotton a mixture of 4 ounce of alcohol and 12 ounces of water. In the above preparation any of the glycero-alcoholic fluid extracts, such as orange, ginger, benzoin, gum myrrh or wild cherry may be added to simple syrup making adjuncts to compounrls of other agents and solvents for inorganic substances.

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Maximum dose is 20mg/day Dosage forms: Capsule, 10mg, 20mg; Tablet, 10mg, 20mg Meloxicam, 7. Pyogenic Osteomyelitis Pyogenic Osteomyelitis is an acute infection of the bone and its structures caused by bacteria. Osteomyelitis occurs as a result of hematogenous spread, contiguous spread from adjacent soft tissues or direct infection from trauma or surgery. Hematogenous osteomyelitis is usually 243 monomicrobial, while osteomyelitis due to contiguous spread or direct inoculation is usually polymicrobial. Coagulase negative staphylococci and aerobic gram-negative bacilli are also common causes. Clinical features Gradual onset varying from few days to weeks of local bone pain, swelling, low grade fever, malaise and weight loss. Osteomyelitis frequently requires both surgical therapy for debridement of necrotic material together with antimicrobial therapy for eradication of infection. Other organs such as the lungs, kidneys, eyes and the hematopoietic system may occasionally be affected. Clinical features See table below: Table 54-1987 American College of Rheumatology revised classification criteria for rheumatoid arthritis Criterion Description Morning stiffness in and around the joints, lasting at least one Morning stiffness. Then reduce dose if possible and administer 5 days a week with an annual medicine holiday for 1 month. Septic Arthritis the term septic arthritis refers to bacterial infection of a joint. It may occur secondary to haematogenous spread (80-90%), contiguous spread (10-15%), and direct penetration of microorganisms secondary to trauma, surgery or injection. Old age, Diabetes mellitus, skin infection, alcoholism, intra-articular injections are some of the common risk factors. Gram-negative bacilli are found as causes in specific situations such as trauma, immunosuppression and very elderly. Clinical features Septic arthritis presents acutely and mostly with a single swollen and painful joint. If synovial fluid gram stain shows gram negative organism-use ceftriaxone with the above dose as first line. Meningitis Acute Bacterial Meningitis Acute Bacterial meningitis is an inflammation of the meninges in response to bacterial infection. The disease is characterised by an intense headache, fever, vomiting, and photophobia with nuchal pain or rigidity and positive meningeal signs. Ethiopia is one of the countries in the so called "meningitis belt" of the Sub-Saharan Africa which spans from Gambia in the West to Ethiopia in the East of Africa. In the past century, several devastating epidemics have occurred cycling on an average of 8-12 years in this geographic area. One striking feature of the epidemic has been its seasonality by which it tends to occur during the dry and windy season between January and May. High index of clinical suspicion is very important for early diagnosis of Acute Bacterial MeningitisTreatment Acute bacterial meningitis is a medical emergency. Institute empiric antimicrobial therapy promptly and adjust it after isolating the etiologic agent. Digoxin, estradiol, oestrogen conjugated synthetic Dosage forms: Powder for reconstitution 500mg/vial and 1000mg/vial C. Adjuvant Therapy: Consider steroids in all bacterial meningitis prior to organism identification. Treatment must start before or withfirst dose of antibiotics to derive any benefit. Migraine Migraine is a paroxysmal recurrent headache unilateral or bilateral lasting 4-72 hours, often preceded by aura and accompanied by nausea and/or vomiting. History, physical examination, and neurologic examination do not suggest any underlying organic disease Danger signs of headache-if these signs are present urgent evaluation is needed New headache in patients under the age of five or over the age of 50 Sudden onset headache that reaches maximal intensity within seconds or minutes the "first" or "worst" headache Progressively worsening pattern of headache Focal neurologic symptoms other than typical visual or sensory aura Fever associated with headache Any change in mental status, personality, or fluctuation in the level of consciousness. C/Is: Coronary artery disease, peripheral vascular disease, hepatic or renal disease; poorly controlled hypertension, sepsis D/Is: Avoid combination with Macrolid antibiotics, Azole antifungals, Protease inhibitors, Efavirenz, Nitroglycerin Dosage forms: Ergotamine Tartrate+Caffeinefi,tablet 1mg +100mg. Prevention of early recurrence-add to abortive therapy to prevent early recurrence. Start the medicine at a low dose and increase gradually until therapeutic benefit develops, the maximum dose of the medicine is reached or side effects become intolerable. Benefit is noticed first at around one month and can continue to increase for three months. If the headaches are well controlled, prophylactic medicine can be gradually tapered and discontinued. Seizure And Epilepsy Epilepsy is a paroxysmal neurologic disorder characterised by a sudden onset of sensory perception or motor activity with or without loss of consciousness due to abnormal, excessive, hypersynchronous electrical discharges from the cortex. Secondary causes include congenital, perinatal injuries, intra cranial tumours, vascular and metabolic, among others. Treatment Objectives Stop seizure Reduce frequency of attacks Treat underlying cause(if any) 258 Non pharmacologic Advice on a healthy lifestyle with good sleep habits and avoidance of excessive alcohol and caffeine. After the second medicine is increased to optimal the first is gradually tapered and discontinued. Antiepleptic medicines should not be discontinued (even if the seizure is well controlled) unless decided by specialist after complete control of seizures for years When to discontinue therapy-this should be decided by a specialist only About 60% of adults whose seizures are completely controlled with antiepileptic medicines can eventually discontinue therapy. In most cases it is preferable to reduce the dose of the medicine gradually over 2 to 3 months. The following patient profile yields the greatest chance of remaining seizure-free after medicine withdrawal. Status epilepticus-refers to continuous seizures or repetitive, discrete seizures with impaired consciousness in the interictal period. The duration of seizure activity sufficient to meet the definition of status epilepticus is about 15 minutes. Status epilepticus has two main subtypes 261 generalized convulsiveconvulsive statusstatus epilepticusepilepticus and nonconvulsiveonconvulsive statusstatus epilepticus. In Ethiopia, based on Oncology Unit of Tikur Anbessa Hospital data it accounts for 20% of all referred cases to the unit. Based on the 2012, one year Addis Ababa Cancer Registry report, breast Cancer is the leading cancer in Addis Ababa City accounting for 25% of all cancer cases in both sexes. Breast conservative Surgery is not recommended as it always needs adjuvant Radiotherapy to reduce recurrence of cancer. Pharmacologic Breast cancer is a systemic disease and micro metastasis occurs even at early stage. Use standared precautions and check leaflet before mixing and administering chemotherapy. Clinical features Asymptomatic (1/4 of patients) "B" symptoms: fi Unintentional weight loss fi10% in six months fi Fever >38fiC for fi2 weeks without evidence of infection. Treatment Objectives 268 Improve symptoms Manage complications Non pharmacologic Patients with early stage and asymptomatic disease should be observed without treatment. Pharmacologic the following are indications for the initiation of specific therapy: Persistent or progressive systemic symptoms Bulky lymphadenopathy that causes mechanical obstruction or bothersome cosmetic deformities Evidence of bone marrow failure (anaemia and/or thrombocytopenia), immune hemolysis or immune thrombocytopenia. This group of diseases are characterised by the dysregulated production of a particular lineage of mature myeloid cells with fairly normal differentiation. Treatment Objectives Achieve clinical and cytologic remission Non-pharmacologic Patients with symptomatic anaemia should be transfused packed red blood cells. Pharmacologic Palliative (Cytoreductive therapy) chemotherapy: First Lline Hydroxyurea, oral, 2 to 4g/day, initially depending on the cell count.

References:

  • https://link.springer.com/content/pdf/10.1007%2F978-3-662-47714-4.pdf
  • http://web.media.mit.edu/~raskar/Eye/TheDirectOphthalmoscope.pdf
  • http://almacen-gpc.dynalias.org/webdav/publico/Recommendations%20for%20the%20management%20of%20patients%20after%20heart%20valve%20surgery.pdf
  • https://issues.org/wp-content/uploads/2020/01/Cooper-Paneth-Precision-Medicine-Winter-2020.pdf
  • https://davisplus.fadavis.com/3976/meddeck/pdf/filgrastim.pdf

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