Wayne Koch, M.D.
- Professor of Otolaryngology - Head and Neck Surgery
https://www.hopkinsmedicine.org/profiles/results/directory/profile/0001225/wayne-koch
Step two of the Rural Framework Wheel provides a visual representation of context diabetes diet vegan purchase 850 mg metformin visa. Analysis has revealed rural society and culture as a discernible but ever-evolving construct managing diabetes pregnancy buy metformin 500 mg amex. This contextual information has laid the foundation to critically analyse how nursing practice is shaped by the rural context diabetes medications and pancreatic cancer order 500 mg metformin free shipping. Health perceptions diabet-x blood sugar support cheap metformin 850 mg online, needs and behaviours of remote rural women of child bearing and child rearing age diabetic diet dinner generic metformin 500mg without prescription. Christchurch type 1 diabetes symptoms yahoo answers buy generic metformin 500mg, New Zealand: National Centre for Rural Health, Department of Public Health and General Practice, Christchurch School of Medicine, University of Otago. The culture of rural communities: An examination of rural nursing concepts at the community level. Rural and remote social welfare practice: Differences and similarities in the Australian context. Locality and social representation: Space, discourse and alternative defnitions of the rural. New Zealand rural general practitioners 1999, survey part 3: Rural general practitioners speak out. Narratives of community and change in a contemporary rural setting: the case of Duaringa, Queensland. Wellington, New Zealand: Department of Public Health, Wellington School of Medicine and Health Sciences, University of Otago. Determinants of health, disease and disability: Differences between country and city. Hidden others: the other, often darker hidden side of rural life where age, gender, sexuality, economic position and disabilities can marginalise and exclude. Country-mindedness is an ideology where rural people see their hard work as primary producers being the explanation for the Australian high standard of living. Mateship is a uniquely Australian social behaviour, where intimate camaraderie exists with a companion. Outsiders are perceived as new or leading a more urban-orientated or non-acceptable lifestyle. Globalisation: a term referring to the change in relationship between space, economy and society. Rationalisation: allocating services based on supply and demand principles, not equity of access. Counter-urbanization: resurgence of the rural population based on net in-migration. Primary Health Care Strategy: a new approach taken by the Ministry of Health (2001) to facilitate improved primary health care and to reduce inequalities. It generated in me an understanding of the structure and functioning of rural communities, the old-timer-newcomer and kinship aspects (Long & Weinert, 1998), and the intrinsic culture. It also helped me develop personal autonomy and responsibility, independence and an optimistic outlook that anything can be achieved if tackled creatively enough. Stewart Island, off the south coast of the South Island, is the third largest in land mass. Information relating to Stewart Island is used throughout this chapter to exemplify island life. An island dweller sees his/her ecosystem stretching far beyond the bounded-ness of their shoreline (McCall, 2002a). The resources of the sea are regarded as their ecosystem and McCall argues that continental people only become islanders when they view the sea, not the land as their home. Examining the rural and remote areas within New Zealand in terms of their links, isolation, bounded-ness, and looking from the inside of these areas towards the outside, gives a clearer view of the way these communities function. This growth and decline, both economic and social, can result in a relative disadvantage compared to the total population of New Zealand (McClintock et al. This in turn brings different demands on the service and supply industries, and can also impact on resources (Gould & Moon, 2000). This runs counter to the urban needsbased assessments of expected service provision levels (Gould & Moon). Island People (Islanders) Island people are regarded as hardy, self-reliant, resilient, capable of hard work, resourceful, and stoic in the face of adversity (Bushy, 2000; Leipert & Reutter, 2005; Long, 1998; Sansom, 1970; Wirtz, Lee & Running, 1998). The lifestyle promotes prepared-ness (Boaz, 2004), a sense of contentment, belonging, and a sense of human scale. Small island locality involves social aspects of bounded-ness and difference, as well as those of geography and resources (Royle, 2001). Lack of anonymity and a lower threshold for intimacy in a small community makes social relations that are more intense (McCall, 2005). Accepted aspects affecting the islander are a sense of belonging, kinship, concepts of outsider/insider, new comer/old-timer, lack of anonymity, familiarity, lay care networks, local sense of time, local language and appreciation of the status individuals hold within the community (Bushy, 2000; Hotchkiss, 1994; Lee, Hollis & McClian, 1998; Smith, 2004). Levine (1987) conducted a social study of the Stewart Island community whilst living on the island, identifying characteristics of harmony, cooperation, civility and community spirit which exist alongside competitive and individualistic characteristics. This attitude enables the fshermen to compete directly for resources at sea but also exist as friends, neighbours and kinsmen in the community (H. Women in rural communities are also known to have involvement in social, land, education and health issues and they are politically active (Rural Women New Zealand 2001; Smith, 2004). Islanders and rural people see themselves as different to people from urban areas (Strasser, 1999; Fraser-Wilson, 2005). An example of this difference is a pervasive sense of preparedness (Boaz, 2004), hardiness (Wirtz et al. In other words if resources are not managed well by the individuals in the community then the survival of the community is at risk (Moore, 1998). As a consequence of isolation, people have fewer interactions and communications with others which can lead to physical, social, political and professional isolation (Lee et al. This in turn leads to increased vulnerability (Bushy, 2000) of both individuals and communities. Health provision In both Australia and New Zealand small rural communities have identifed health service provision as vital for community security, and reduction of services attributes to increased vulnerability, and possibly community decline (Farmer, Lauder, Richards & Sharkey, 2003; Strasser, Harvey & Burley, 1994) while appropriate health care increases resilience and strengthens communities. It is generally accepted that rural people tend to conceptualize health using a role performance model and have a health belief based around their ability to perform their activities of work and family life (Elliot-Schmidt & Strong, 1997; Long, 1998; Smith, 2004). Their stoic hardy attitude is also demonstrated in small island communities (Swain, 1970). Islanders and rural people become attached to long serving health providers, mistrust non-islanders or non-locals (Gould & Moon 2000; Strasser et al. Extreme environments and, in some cases, inherent danger, economic challenge, as well as limitations on political power, jurisdiction and choices for further development, add to the challenge of isolation and smallness. Island health care involves workable communication systems, collection of good information, transport and appropriate access to specialist services enabling accessible acute and primary health care (Scottish Health Services Advisory Council, 1995). Appreciation of local skills and culture, locally devised solutions and a generalist approach to health care provision have been identifed as features specifc to island populations (Hotchkiss 1994; Royle 1995; Ministry of Health 2002; Scottish Health Services Advisory Council, 1995) and are also parallel to the health service needs of rural and remote communities (Bushy, 2000; Lee et al. Kelman (2004b) explains that island communities by nature have increased vulnerability or susceptibility and this is paralleled in rural communities (Gould & Moon, 2000). This can lead to health issues due to infectious disease, economic challenge, damaging social and political insularity, strategic signifcance and the consequences of this, environmental factors such as water and food provision, and natural hazards (Kelman, 2004b; Lewis, 2001). These issues lead to specifc health outcomes and service needs requiring provision of emergency and primary health care (Gould & Moon). Positive features of island health care, noted from a review by Hotchkiss (1994) include: a local orientation towards primary care, easy access to local services, care from generalists, respect for local practices and recognition of the need to establish and maintain links with larger centers for professional development and service provision. A socio-ecological approach examines a deep ecology of collective questioning of basic assumptions about our world, culture, life and our relationship with the environment (McMurray). The New Zealand Primary Health Care Strategy (Ministry of Health, 2001) focuses on generalist frst level services, community participation, health promotion and prevention, timely and equitable access and a high performing system which engenders confdence to improve health status and reduce inequality in health care. Island communities have unique health needs and require the local health professionals to acquire specifc competencies to meet the needs of the island population. Health care in island communities is usually provided by nurses, and they demonstrate advanced nursing practice (Bushy, 2000; Galea et al. The focus of a generalist involves individual, family and community health care, and they practice comprehensive models of care by assessing, diagnosing, planning, intervening and evaluating (Ervin, 2002). Rural nursing competencies Specifc competencies related to the provision of health care by island nurses have been identifed and include advanced emergency care, advanced assessment and diagnosis, community assessment, health promotion, health prevention, health screening, curative skills including minor surgery and pharmaceutical treatments, management for specifc populations (such as pregnant women), critical thinking and problem solving skills (Bushy, 2000; Lee et al. The nurse was required to have integrity, strength under adversity, and impeccable confdentiality and reliability (Swain). The competencies that Swain exemplifed are echoed in the obituary written as tribute to the exemplary career of Jemima Sutherland, a nurse who worked on small islands, mainly the island of Unst, in the United Kingdom (Stickle, 2005).
H+) diabetes prevention outcome measures buy metformin 500 mg with mastercard, pressure or hot/cold fi Sensitivity to noxious stimuli fi by prostaglandins (long chain fatty acids derived from arachidonic acid) metabolic bone disease icd 10 500mg metformin with visa. Can be antagonised by naloxone fi Gate theory: large fibres send inhibitory collaterals to presynaptic C fibres fi Referred Pain: visceral pain felt in somatic structures diabetes test doctor generic 850mg metformin. Morphine agonises all receptors giving strong analgesia diabetes in dogs care order metformin amex, respiratory depression (both mediated Anaesthetics 543 through M receptor) and dependence blood sugar range for diabetics cheap 850mg metformin with amex. Pentazocine is a weak M-receptor antagonist and strong kreceptor agonist and produces weaker analgesia diabetes leg cramps purchase 850 mg metformin amex, low dependence and little respiratory depression fi Uses of opioids: fi Relief of pain fi To supplement regional and general anaesthesia fi As primary anaesthetic agents fi Premedication to allay anxiety and sedate fi Specific indications. Donfit inject through wound edge of unsterile wound fi Nerve block: large area of analgesia, fewer injections, smaller doses fi Extradural: between dura mater and periosteum of vertebral canal. Pethidine): variable satisfaction, dissociative, safe (midwives can use it), can fi respiratory depression in neonate fi Psychoprophylaxis: very effective. Resting diastolic pressure over 100 mmHg should delay elective surgery until better controlled. Hypotension and rapid weak pulse fi See Management of Mild-Moderate Dehydration, page 650, for fluid management in children th th 550 4 and 5 Year Notes Types of Replacement Fluids fi Crystalloids: isotonic, short intravascular Tfi. For treatment of water loss or when sodium restrictions are present: fi Barts: 4% dextrose/0. More readily available than blood and no infection risk, donfit require cross matching. Kidneys take time to excrete, so watch for fluid overload, especially in renal impairment and kids fi Haemaccel: polygeline (degraded gelatine) plus electrolytes (145 mmol/L NaCl + 5. Haemaccel and crystalloids can be microwaved Child Requirements fi Maintenance fluid: 4% dextrose + 0. Losses decrease with renal failure fi See Management of Mild-Moderate Dehydration, page 650 Adult requirements fi Adult daily requirements: fi 2. Maximum rate of potassium replacement is 20 mmol/hr Burns fi Burns fi rapid loss fi secondary organ damage. Not the same as below the normal range, as normal range includes functional reserve) fi What is the appropriate blood product fi What is the correct dose to transfuse fi Has the transfusion workedfi Intermittent flushing with saline helps fi If hemiplegia, or mastectomy, insert in good arm fi Infiltration/tissuing is leakage into surrounding tissues. Obtain verbal consent fi Choice of gauge: age, flow required, whatfis being infused. Malnourished need feeding Enteral Nutrition fi Adult energy requirements: 40 Kcal/kg/day (approx. Stop at night if they can tolerate increased flow during day fi Tradeoffs: fi When sick, fi motility and fiemptying. Need to be minimal volume but still flow through tube fi Donfit include lactose as filactase when sick. X-ray after insertion to check no pneumothorax and line is outside pericardium (above anterior third rib) to avoid cardiac tamponade following catheter erosion fi Complete nutrition: electrolytes, glucose, amino acids, fat emulsion, vitamins, etc. Fat a good way of giving calories without figlucose (which could fi diabetes) fi Other major risk: sepsis. Colony count should be 5 times higher in central line sample than in peripheral blood fi Metabolic problems common. Treat with naloxone (but short Tfi so may need to repeat) fi Delirium tremens (alcohol withdrawal) fi Urinary retention fi No cause found fi Management: Quiet, gently lit area, familiar faces. See Development Chart: normal development from 0-60 months, page 576 Paediatrics 563 fi Past medical history fi Social/school fi Medications fi Allergies fi Family History: ages and health of parents and grandparents. E hua whakatairantitia Rere ki uta, rere ki tai Mau e ki mai He aka the mea nui o the aofi Maki e ki atu, He tangata, he tangata If you pluck the young shoot of the flax bush, where will you find the bellbirdfi Read books about hospital fi Reassure your child that you will be there too fi Answer your childfi questions fi Use simple terms that the child can understand fi Take a favourite toy. Birth asphyxia fi Deaths thought to be related to an instrumental delivery Behavioural Issues fi Behaviour doesnfit exist outside an environmental context Behaviour Management fi History Taking: fi Antecedent: what sets him offfi Somewhere safe and boring, and where you donfit mind the child disliking (ie not the toilet if toilet training or bedroom if sleep training). Indicators of serious disturbance include: fi Deliberate self harm or messing fi Wandering off fi Running away fi Age inappropriate sexual behaviour fi Developmental sequence of everyday habits: fi Feeding fi Sleeping fi Eating fi Toilet Paediatrics 571 fi Going to bed and getting up fi Dressing and undressing fi Washing and cleaning teeth fi Aim is to achieve regular habits and routines: fi To start with need to insist on regular routine and time schedule. Once achieved can be more flexible fi Failure to achieve routine: daily hassle and distress fi Regular routines fi fisecurity of child, fiargument with parents fi Factors which fibehaviour problems: fi Routine and regularity fi Clear limit setting fi Unconditional love and affection fi High level of supervision fi Consistent care and protection fi Age appropriate disciplines and rewards fi Tantrums: fi Want their way. If you say no, will have to stick with it fi choose your battles fi Options for managing a tantrum (see Behaviour Management, page 570) fi Ignore it: eg leave the room fi Time out fi Distract fi Avoid problem areas (eg supermarkets) fi Things will get worse before they get better. Struggles for autonomy and mastery produce normal tantrums fi Types of Attachment Disorder: fi Disinhibited type: will go to anyone. Likely to be due to abuse fi Test by observing child when parent leaves (separation), when a stranger comes in, and when parent returns (reunion) Domestic Violence fi Has significant health consequences: injury, psychiatric, chronic pain, drug and alcohol abuse fi Is common (some studies report up to 20% of women being hit in the last year), but often missed by doctors fi Domestic violence starts with a cycle of increasing control and disempowerment. In my experience, many of these women are being hurt in some way by their partner. Get better rapport than starting at the upper limit and working down fi Hearing: What things can he hearfi No head Grasp Reciprocal vocalisation, laugh Turn head to voice Reciprocal smiles lag on pulling up Retain 1 block Localise bell/keys (horiz) Up on hands Take 2 blocks Consonants Localise bell/keys (vert) Lifts arms for pick up Sit supported Transfer hand to hand Mono-syllabic babble Sit stable Object permanence: Take 3 Vocalise to communicate Understands no, ta Peekaboo Cooperate with Pull to stand blocks 1 at a time and hold onto Poly-syllabic babble Localise bell/keys (diag) dressing Crawl them Jargon Bang, index point Move around furniture Good pincer Few words with meaning Shake head for no Push toy car Independent with Copy bye bye Clap hands cup Walk independent Stack 2 blocks Several words Understands object names Push large wheeled toy Remove item Mark paper with pencil, fist grip Wave bye bye on request Casting prom. Count bricks Plurals 42 mo: fetch several items Name friend Pedal; Up stairs adult Share, turns Hop 3 steps/ Jump off 2 5 brick gate Intelligible to strangers Prepositions: between Gives age Undress indep. Tenses Opposites: big/little Co-op play, hide n seek, snap Down stairs like adult Cut with scissors; Higher, longer Constant Qs: where, why What would you do iffi Instead, does he do age appropriate work, need extra tuition, etc Cognitive Development fi Overall process: fi Autonomy: dependent on parents fi peers fi independent fi Abstract thinking (what iffi Usually (80%) non-disjunction at first meiotic division fi 5% have different karyotypes: fi Mosaic Down: 3 % fi Robertsonian translocation t14:21: 4. Chromosomal anomalies represent 15% of congenital anomalies fi Risk: Maternal age at birth Down in live births 25 29 1:1100 30 1: 900 35 1:350 37 1:200 40 1:100 43 1:50 45 and over 1:25 fi Neonatal Screening: fi Only 30% of children with Down are born to women over 35. More complicated when some ongoing vigilance is required fi Support appropriate attitudes and plans fi Mobilise family support fi Remain optimistic fi If in hospital, use separations to reinforce that parents will return. Limited number and consistency in nursing staff Pre-schooler fi Social and emotional development may be limited through lack of opportunity to achieve goals in play and by limited peer interactions fi Management: fi Refer for early intervention, especially low socio-economic and disabled children fi Promote normal development: separation, appropriate discipline fi In hospital: encourage rooming in, maximum contact with families fi Warn parents to anticipate behavioural problems especially if hospitalisation is prolonged or frequent Head injured child fi Initial crisis: grieving put on hold, waiting to see if things improve, child still looks the same, swinging between hope, despair and disbelief fi Restructuring: fi Reassign tasks in the family fi Move out of crisis reorganisation into long term reorganisation fi Inclusion of outside help into family fi Appropriate time for husband/wife/other children fi Time for self fi Grieving: fi Allow for grief and acknowledge the loss fi Avoid dichotomy of one person (eg mother) taking hope position and others despair fi Promote openness. Devastation of silence fi Denial can also be a coping mechanism fi Develop an acceptance of a new identity through the crisis: fi Seeing how the child is different fi Finding positives in this new identity and helping the family value these fi Achieve a sense of movement through the crisis. Removes guilt, pejorative labels (eg lazy), gives optimism fi Bypass strategies: adjust rate, volume, complexity, format or use devices to make the task easier fi Remediation of skills: focus on study skills, organisation, use strengths to remediate weaknesses fi Developmental therapies: Eg speech therapy, gross and fine motor, etc. More effective when skill deficits reflect lack of opportunity, and when instituted earlier fi Modify the curriculum: Eg drop subjects theyfire not succeeding in fi Strengthen strengths: sport, art, mechanics, etc fi Individual/family counselling: especially with behaviour management, family dysfunction fi Advocacy fi Medication fi Longitudinal case management fi Check whether parents get the child disability allowance. In a 5 year old this can cause a range in growth th th velocity from 10 to 50 centile fi Taller in morning than at night fi Minimising error: Same measurer, calibrate regularly, careful measurement, donfit look at last measurement, measure at beginning and at end of exam Short Stature fi Definition: th fi > 2 standard deviations below the mean = below 5 centile fi Reduced growth velocity fi Exclude failure to thrive fi Growth pattern is more important than height fi Normal variants: fi Familial (genetic) short stature fi Constitutional delay of growth and development. Male = female + 13 cm or average their centiles) fi Family history: eg constitutional delay fi Systems fi Psychosocial fi Development fi Examination: fi Growth parameters fi Dysmorphic features fifi Child more vulnerable to pain and stress-induced exacerbations fi Occurs at least monthly for a three-month period. May slow due to maternal drugs (eg pethidine) fi Tone: 2 for active movement, 1 for limb flexion fi Response to stimuli: On suction, 2 for coughs well, 1 depressed fi Apnoea: fi Primary Apnoea: pulse < 60 and cyanosis. Takes ~ 48 hours for ductus to close fi Other observations: fi Micturition: usually soon after birth, infrequent for first 24 hours fi Bowel: 99. Cystic Fibrosis, Hirshprungs fi Jaundice: 40% develop it, but transient, resolves by day 5 fi Vomiting: a little is common. See Genetic Testing, page 465 Outcome after Preterm Birth fi At 27 weeks, 90% survive to discharge fi Definitions: fi Prematurity: < 37 = weeks Preterm, < 33 = weeks Very preterm fi Birth weight (fi Associated with maternal infection Paediatrics 589 fi Frontal, usually watershed lesion fi Cysts long term fi spastic diplegia (legs worse than arm) fi Retinopathy of Prematurity: Abnormal vascularisation of retina following exposure to high O2 concentrations. If nipple then repeated trauma fi pain, cracked nipples, etc fi Mastitis or blocked duct fi express lots (try it in the bath) fi Establishing bottle feeding: fi Day 1: average intake 60 ml/kg (= 40 calories/kg) fi fi by 15 ml/kg/day until average of 150 ml/kg/day fi If too much then fistools, fivomiting, fimisery fi Alternatives to cows milk: goat (but no folate), soya, hydrolysed (if allergic to everything else) fi Allergy: eczema reaction mainly to casein proteins, but can also be allergic to whey protein fi Can be intolerant (ie non allergic reaction) to: fi Lactose (galactose + glucose): filactase fi osmotic diarrhoea + fifermentation by bacteria fi figas fi frothy acid stools fi acid burns round perianal skin. Parents may need reassurance fi Non-organic failure to thrive: fi Inadequate parenting/poor nutrition the most common cause (will feed and gain weight well while in hospital). No energetic games beforehand fi Approach to Sleep Training: fi Agree with partner/family what you are going to do fi Plan in advance (eg start on a long weekend). Warn neighbours fi Tell the child how it is going to be and why fi Quiet bedtime routine every night fi Put in bed, say good night, walk out fi If they come out, return them to bed with no reinforcement or eye contact fi If they cry, wait 5 minutes, then 7 minutes, then 9 minutes, etc. Prevent by varying position of the head when lying th th 594 4 and 5 Year Notes Neonatal Acute Airway Problems fi Choanal Atresia: failure of formation of nasal passages. Beware the midline lesion fi Pierre Robin Sequence: short jaw, cleft palate and tongue falls back and obstructs. Associated with oligohydramnios fi Subglottic Stenosis: due to intubation trauma in a preterm baby Hypoglycaemia of the New Born fi Not a big deal, but needs to be recognised and managed fi Causes (either big babies or small babies): fi Hyperinsulin: Child of poorly controlled diabetic mother. Have high index of suspicion, low threshold for antibiotics fi Respiratory Distress Syndrome: X-ray appearance: Ground glass + air bronchogram fi fisurfactant. If maternal diabetes, are deficient in surfactant until later in gestation fi Aspiration: meconium, milk, blood fi Pulmonary oedema, hydrops fetalis (fi in heart failure before delivery. Used to be due to Rhesus negative disease prior to Anti-D treatment, now numerous other causes) fi Lung haemorrhage: complication in premature fi Primary lung disease fi Cardiac causes of cyanosis: fi R to L shunt: Cyanotic heart disease or pulmonary hypertension fi L to R shunt and Heart failure fi Differentiating Heart and Lung Disease: fi History and exam: fi When did it start fi Relationship of cyanosis to birth. If heart, pink to start with then go blue as ductus closes (blood gets to lungs via reverse flow through ductus if right heart not functioning well) fi Check respiration: fi If apnoea fi heart. Higher in stillborn and premature births fi Aetiology unknown in > 90% of cases fi Pathogenesis: fi Septum primum closes foramen primum at week 5.
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The relief of the high plateaus where the deposits are located is very mild and presents no difficulties for herds of oxen or sheep diabetic weight loss buy metformin 850mg low price, which are still today moved seasonally in summer to these high pastures pracTical means of inTeracTion: specializaTion and moBiliTy the site of godedzor does not appear to be a sedentary or continuously occupied settlement diabetes diet research articles discount 500mg metformin otc, and the mobile way of life of its population would have been the consequence of a subsistence strategy based on herding diabetes symptoms for dogs buy metformin 850mg on-line. This evidence for the development of pastoralism in northwestern iran around the end of the fifth millennium is part of a wider phenomenon that concerns a large part of the zagros diabetes in dogs and ketones purchase genuine metformin on line. The hypothesis of specialization and mobility of the population of godedzor is supported by several arguments blood glucose 94 generic 500mg metformin visa. There are very few architectural remains: the only traces of habitation type 2 diabetes juice fasting generic metformin 500mg with visa, which belong to the upper horizon of the chalcolithic layer, consist of vestiges of circular walls with only one course of stones. The remains of the small domestic ruminants attain about two-thirds of the identified sample and, although less than one-fifth of their bones were well enough preserved for species identification, it is worth mentioning that almost all of them are from sheep. Without doubt, cattle and sheep would have been most useful within a herding system based on transhumance, and cattle would have been used for transportation of heavy loads, as the deformed vertebra suggests. The scarcity of heavyduty tools (grinding slabs and pestles) is also noticeable. The high plateau where godedzor is situated lies near large obsidian deposits, but only a limited quantity (limited in particular by the weight of the material and the fact that the pack or draft animals would have been already heavily loaded with tents and belongings) could have been brought down for personal use or for local trade. Cervus elaphus, Bos primigenius, and Bison bison contributed about 25 percent of the animal bone weight. Wild boar (Sus scrofa), wild sheep (Ovis orientalis), wild goat (Capra aegagrus), and the onager (Equus hemionus) were other hunted ungulates. The diversity of the environment (forest, steppe, mountain) frequented by these wild animals could correspond to the number of different ecological niches crossed (and exploited) during the seasonal movements of the group. These were characterized, in particular, by architecture in pise or mudbrick and agriculture that was highly developed in quantity and variety (Triticum monococcum, Tr. The sioni complex, which succeeded the aratashen and shulaveri-shomutepe cultures in the first half of the fifth millennium, is also indicative of a development toward a pastoral way of life: near-absence of constructed architecture, post holes indicative of light constructions, circular ditches considered to be enclosures for livestock (varazashvili 1992). The pottery, however, is very different from that of godedzor, as much in the technique (mineral temper is preponderant) as in the shapes or decoration (notches on the rim, rows of perforations or protuberances). This is why the pottery assemblage at godedzor, which consists of coarse chaff-tempered ware and fine pottery with painted decoration, appears to be exogenous. The fact that the whole pottery assemblage moved would be another proof of mobility. The central part of these mountains and the khuzistan steppe have yielded a few neolithic sites (ganj oi. True agricultural villages also appear in the uplands of the zagros at about the same time (eighth millennium b. The area was probably occupied by nomadic pastoralists, as this valley provides excellent resources for herders (danti, voigt, and dyson 2004). The general deterioration of the climate at the end of the middle chalcolithic period, accompanied by overgrazing, is also emphasized by abdi (2003), who considers it likely that more and more people turned then to mobile pastoralism as a viable subsistence strategy. This phenomenon may have been related to the expansion of political and economic relations with (and influences from) southern mesopotamian settlements during the Ubaid 3 and Ubaid 4 periods, in coincidence with the emergence of power groups that established forms of control and competition for local and exotic resources (but see. With the archaeological data available at present, it is possible to hypothesize the existence of complex societies from the end of the fifth millennium, when processeses of social stratification and specialization of production were slowly taking place through unequal access to and manipulation of material and ideological resources (rothman 2001; akkermans and schwartz 2003). The pottery production of godedzor fits well into this picture of growing interregional relationships and enlarged cultural horizons. The chaff-tempered production reflects similar technologies that were widespread in the oi. But while the introduction of these new techniques in these areas could have been related to shifts toward mass production and cost reduction, their use in the settlements of the more peripheral regions may have been related to the needs of the local populations. The presence of the north iranian painted pottery, which among the decorated ceramics is the most common group, and the evidence of mobility suggest that the origins of the communities who settled at godedzor should be sought in the region of lake Urmia. The few sherds of Ubaid-like pottery could have been transported by these groups from their places of origin to neighboring areas during seasonal migrations. The site was possibly located on the edges of a region that was within the interaction sphere of the Ubaid-related communities of northwest iran. To the north, that is in the lesser caucasus and the ararat plain regions, the local communities were developing at a totally different and autonomous pace (sioni complex). The borders were probably very fluid and elastic, and not linked to forms of territorial control, being shifting cultural boundaries related to the main activities (in this case specialized pastoralism) carried out by the communities from the lake Urmia area in shortor medium-range interactions. Thus, these boundaries shifted according to the directions chosen by the local transhumant groups during the course of their seasonal movements. The study of the pottery is entrusted to giulio palumbi (Universita, la sapienza, rome, italy), the chipped stone to Boris gasparyan (gfoeller foundation), the bone artifacts to rosalia cristidou (archeorient, lyon), the fauna to hans-peter Uerpmann (Tubingen, germany) and carine Tome (cepam, valbonne), and the plant remains to roman hovsepyan (institute of Botany, yerevan) and george Willcox (centre national de la recherche scientifique, lyon). Technical editing: Solveig Bang Catholic Relief Services is the ofcial international humanitarian agency of the United States Catholic community. Politically, Cameroon is stable, but the situation is somewhat tenuous as the current president has been in power for more than 30 years, and there are restrictions of the freedoms of expression, association, and assembly. This exodus was exacerbated by from Central African Republic bandits known as zaraguinas who specialized in kidnapping children for in 2007 1. See preliminary crS report on car by this author, December 2015 for extensive background on the situation in car. The Seleka rebel coalition had seized territory, resulting in the March 2013 coup. The antifibalaka are commonly identifed as Christian, while the Seleka are often associated with the Muslim identity. This study found that many interviewees were similarly expressing fears of instability at the national level due to potential national leadership 6. Stabilization of the political Many refugees reported that they had voted, and many were cautiously and economic situation in hopeful that peace and stability would come. Based on a desk study, key issues that could lead to violent confict were identifed, then key informant interviews conducted in Yaounde and eastern Cameroon. Key actors mobilize people and resources to engage in violence, based on grievances. Interviewees were selected based upon the identifcation of key issues that could potentially cause confict, and then key actors for peace and for confict were targeted. The teams conducted 135 interviews with 165 people in the east, and 12 interviews with 14 people in Yaounde. Religious identities included 24 Catholic, 84 other Christian, 58 Muslim, and 12 unknown. Due to the selection criteria of key actors such as religious leaders and security forces, and the necessity to meet frst with local authorities and traditional leaders in each research site, many more men than women were interviewed. There were also only 3 women among the 14 study team members, and only one of the 14 was Muslim. Three teams of 4 people (see Appendix 1 for list of team members) underwent 3 days of training, then each team spent 10 to 12 days in the feld, with the consultant conducting additional interviews in the east Region and Yaounde. Interviews were semifistructured and data collected was qualitative except for the demographic information on each interviewee. At the end of the data collection period, each team fnalized all their data and prepared a presentation that was discussed in a twofiday debrief session. During the debrief, response options were developed by each team, and were then discussed in the larger group. This report is the expanded version of those validated results, supplemented by a review of the literature and another review of the data. In 1972, it Cameroon has been widely became the United Republic of Cameroon under a new Constitution. In praised for its ability to 1982, Paul Biya became President, and remains so today after ensuring maintain the calm and a constitutional amendment in 2008 that removed the twofiterm limit. Cameroon has great geographical and cultural diversity and its ecosystems range from tropical forests to highland savannahs, including beaches, mountains (and an active volcano), and deserts. It is rich in natural resources (including minerals, oil, natural gas, and water). However, corruption, political obstacles, and lack of infrastructure have hampered development. The legal system is mixed between (French) civil law, (British) common law, and customary law. Paul Biya has been president since 1982 (almost fve 7fiyear terms), and Philemon Yang has been prime minister since 2009, appointed by the president. In the 2011 election, Biya obtained 78 percent of the vote, which was labeled as fawed, but not enough to have a signifcant impact on the outcome. Although the Supreme Court received submissions of 40 challenges, none were accepted,19 and the results were declared free and fair. President Biya has been described as extremely skilled in balancing the very complicated regional, political, and ethnic power dynamics of the country, and many observers have expressed concern about the lack of a public succession plan, and fear of disruption or instability in his absence, especially given his age of 83 years. Traditional methods of dispute resolution are often used, especially in the North and Far North, but these sometimes resulted in allegations of arbitrary detention against some traditional leaders. While the country rights, and is signatory to the has been politically stable, there have been allegations against the major international human President of electoral irregularities and oppression of the opposition; rights instruments. The government has been reported to monitor political meetings and has threatened and harassed those who criticize the government; critical journalists have been silenced using libel laws as well as through violence and arrest. Although the government took some steps to punish and prosecute ofcials who committed abuses in the security forces and in the public service, these actors were often still able to act with impunity. There are 10,854 refugees and approximately 6,000 asylum seekers from Cameroon living outside the country. There are also 10,600 refugees living in the Yaounde urban area, and further 7,700 in the major city of Douala. Others share homes with host families, have built their own shelter, or are living in the open. These are GadofiBadzere, Mbile, Lolo, Timangolo, and Ngarisingo (See map in Appendix 3). The other 70 percent have settled into host villages, which generally set aside tracts of land where all the refugees can set up a community within the village boundaries. For the refugees, this exercise will include the delivery of new and standardized refugee certifcates, new ration cards and the renewal of identifcation cards. In the longer term, biometric registration is critical for obtaining reliable data on refugee movements and statistics. When refugees leave the camps in search of livelihoods (many complain of insufcient support in the camps), the Cameroonian authorities are reported to arrest them and force them back to the camps. There continues to be some movement across borders, especially by cattle herders who have done so for centuries. However, of the total 460,000 refugees outside of car, the majority of whom are Muslim, only 26 percent were registered to vote. Both candidates promised peace, security, unifcation, and reconciliation of the country.
Preexisting cognitive impairment in patients scheduled for elective coronary artery bypass graft surgery diabetic cat order 500mg metformin with amex. Cognitive impairment in older adults with heart failure: prevalence diabetes pills names generic metformin 850 mg free shipping, documentation metabolic disease what is it buy metformin online from canada, and impact on outcomes diabetes diet education buy discount metformin 500 mg on-line. Cangrelor infusion is associated with an increased risk for bleeding: metaanalysis of randomized trials diabetes type 2 ziektebeeld buy metformin mastercard. Which of the following is correct regarding the normal anatomy and physiology of the pericardiumfi It allows great distention of the cardiac chambers and increased cardiac filling B diabetes prevention games order metformin american express. The human pericardium consists of two distinct layers, the inner serosa and the outer fibrosa D. A 49-year-old man presents to clinic with pleuritic chest pain, myalgia, and fever. Which of the following findings is not a diagnostic criterion for acute pericarditisfi Which of the following is a Class I level A recommendation on the proper diagnosis and management of pericardial diseasesfi Corticosteroids should be prescribed as first choice in patients with acute pericarditis B. Vasodilators and diuretics are recommended in the presence of cardiac tamponade C. An absolute contraindication to draining a pericardial effusion includes a suspicion of bacterial etiology D. Which of the following is not a recommended therapeutic option for recurrent pericarditisfi A 40-year-old woman presents to the emergency room with chest pain, fever, and night sweats. Which of the following findings is not consistent with a diagnosis of tuberculous pericarditis with pericardial effusionfi Negative acid-fast bacilli staining and mycobacterium cultures on pericardial fluid E. Which of the following clinical presentations is consistent with cardiac tamponadefi A 63-year-old man is brought to the emergency room with altered level of consciousness and is found to be tachycardic and hypotensive. Echocardiography reveals a large pericardial effusion with echocardiographic evidence of tamponade. Which of the following is not appropriate in the subsequent management of this patient with cardiac tamponadefi If a pericardial catheter is placed, removal of the intrapericardial catheter when the output is < 90 mL over a 24-hour period B. Pericardiocentesis should be guided by echocardiography to prevent tissue injury D. If a pericardial catheter is placed, reassessment of effusion size and areas of loculation before catheter removal E. The thickened pericardium has decreased compliance, resulting in ventricular interdependence C. Which of the following is most likely to provide definitive treatment for symptomatic patients with constrictive pericarditisfi Pericardial cysts are usually symptomatic and tend to increase in size over time D. This monolayer of serosal cells covering the surface of the heart and epicardial fat is also called the visceral pericardium, whereas the fibrosa and the reflection of the serosa make the parietal pericardium. No adverse consequences follow congenital absence or surgical removal of the pericardium (option B). It limits distension of the cardiac chambers and facilitates the interaction and coupling of the ventricles and atria (option A). Limitation of cardiac filling volumes by the pericardium may also limit cardiac output and oxygen delivery during exercise. Acute pericarditis is usually characterized by sharp retrosternal pain (option B) that is aggravated by lying down and relieved by sitting up; its onset is often heralded by a prodrome of fever, malaise, and myalgia. The most specific physical sign can be the presence of a pericardial friction rub (option D), which is identifiable in no more than a third of cases. In addition, echocardiographic identification of pericardial effusion confirms the clinical diagnosis of acute pericarditis (option E). Elevated fever (option C) is a major indicator of poor prognosis but is not a diagnostic criterion. The essential indications to drain a pericardial effusion include: cardiac tamponade (therapeutic pericardiocentesis), a suspicion of bacterial or neoplastic etiology, and persistent moderate to large pericardial effusion without response to medical therapy (Class I recommendation, level of evidence: C) (option C). After failure of medical therapy, pericardiectomy can be considered (option C), 3 although it should be performed in centers with specific expertise in such surgery to achieve the best outcomes. Tuberculous pericarditis results from hematogenous spread of primary tuberculosis or from the breakdown of infected mediastinal lymph nodes, with the result that affected individuals generally lack the typical symptoms and signs of pulmonary tuberculosis (option A). In developing countries, tuberculosis continues to be the predominant 4 etiology, accounting for 50% to 60% of cases. Bacterial and mycobacterial cultures should be performed if bacterial infection or tuberculosis is suspected, respectively. Acid-fast bacilli staining (option D), adenosine deaminase, pericardial lysozyme, and interferon-fi levels, as well polymerase chain reaction testing, should be added in the evaluation of tuberculous pericarditis. Nonspecific blood markers of inflammation, such as the erythrocyte sedimentation rate, Creactive protein (option E), and white blood cell count, usually increase in cases of pericarditis and can support the diagnosis. As intrapericardial pressure rises in patients with cardiac tamponade, elevated pericardial pressure is transmitted to all four chambers, affecting diastolic filling. Inspection of the jugular veins will show elevation in central venous pressure (option D); venous distention may or may not be present. Analysis of the venous wave contour will reveal absence or blunting of the y descent, representing impaired ventricular diastolic filling (option B). Because early diastolic filling is profoundly impaired, a third heart sound should not be present (option C); its occurrence suggests an alternative diagnosis. For unclear reasons, tamponade does not usually lead to pulmonary edema (option A); the lungs are often clear on auscultation in patients with isolated cardiac tamponade. The procedure should be done with transthoracic echocardiographic guidance by an experienced operator (option C). During echo-guided pericardiocentesis, the largest collection of fluid in closest proximity to the chest wall should be identified, defining the optimal site for needle entry. Complications include cardiac or coronary perforation, hemothorax or liver injury, pneumothorax, and pneumopericardium. The pigtail catheter should not be removed until the output is < 30 mL over a 24-hour period (option A). Before the intrapericardial catheter is removed, a limited echocardiogram is often repeated to reassess the effusion size and areas of loculation (option D). As a consequence, cardiac filling pressures increase, and cardiac output falls as stroke volume decreases. With respiration, an increase in preload in one ventricle occurs at the expense of filling in the other (ventricular interdependence) (option B). Patients with constrictive pericarditis typically present with features of right-sided heart failure (option D), manifested by elevated venous pressure, ascites, and leg edema. Orthopnea and paroxysmal nocturnal dyspnea are not usually observed and suggest another etiology (option C). Pericardiectomy is the surgical removal of the pericardium, and the procedure is applicable to all variants of pericardial disease. Some patients presenting with cardiac tamponade demonstrate features of constrictive pericarditis immediately after pericardiocentesis is performed and tamponade relieved, such as in the case of those with effusive constrictive pericarditis. In such cases, therapy should be focused on treating active inflammation; a subset of patients might develop chronic constrictive pericarditis and require pericardiectomy following the pericardiocentesis (option B). Therefore, close follow-up of patients with effusive-constrictive pericarditis is recommended (option D). Patients with pericardial cysts are usually asymptomatic, and the cysts tend not to increase in size (option C). Some patients with pericardial cysts complain of atypical chest pain or dyspnea, most likely as a result of compression of contiguous structures (option D). For patients with symptoms 5 related to the pericardial cyst, percutaneous drainage or surgical removal can be performed (option E). However, given the risks associated with both procedures and the benign, well-tolerated course of the disease, observation is likely most appropriate for the majority of patients with pericardial cysts (option B). Tailoring diagnosis and management of pericardial disease to the epidemiological setting. Contributors and editors cannot be held responsible for errors, individual responses to drugs and other consequences. The Standard Treatment Guidelines are intended to promote equitable access to affordable medicines that are safe, effective and improve the quality of care for all. The Essential Medicines List requires regular review of medicine selection based on changes in a dynamic clinical and research environment. It has been promoted as one of the most cost-effective ways of saving lives and improving health. This edition of the Primary Healthcare Level Standard Treatment Guidelines and Essential Medicines List is the culmination of many months of intensive and painstaking review. The commitment demonstrated by the Expert Review Committee to interpret and contextualise the clinical evidence is sincerely appreciated. In addition, we were privileged to have the collaboration of many stakeholders during the review process. We should not forget that the implementation of these guidelines will require similar focus and commitment. It is for this reason that I call upon all clinicians at all levels of care to actively support the implementation of the Primary Healthcare Level Standard Treatment Guidelines and Essential Medicines List in pursuit of realising our vision of a long and healthy life for all South Africans. Evidence based medicine selection principles and consideration of practical implications were applied during this review. To promote transparency, in this fifth edition, revisions are accompanied by the level of evidence. All evidence based suggestions submitted through a national call for comment were deliberated. In addition, there was extensive collaboration with health experts, National Department of Health programmes and clinical societies. In keeping with our National Drug Policy, it is the responsibility of every healthcare professional in our country to support the effective implementation of the revised guidelines. Therefore, I call on all stakeholders in the medicine management system including Provincial Departments of Health, Pharmaceutical and Therapeutics Committees, Health Care Managers, Supply Chain Managers, and every health care professional in South Africa to use and promote the implementation of these revised guidelines. I congratulate the review committee and external stakeholders on a successful collaboration and revision, and I thank them for their continued commitment to healthcare provision in South Africa. We also thank the many stakeholders (dieticians, nurses, pharmacists, doctors, professional societies and other health care professionals) for their comments and contributions with appropriate evidence. The willingness to participate provided additional rigour to this peer review consultative process. Essential medicines are intended to be available within the context of functioning health systems at all times in adequate quantities, in the appropriate dosage forms, with assured quality and adequate information, and at a price the individual and the community can afford. Effective health care requires a judicious balance between preventive and curative services. A crucial and often deficient element in curative services is an adequate supply of appropriate medicines. In the health objectives of the National Drug Policy, the government of South Africa clearly outlines its commitment to ensuring availability and accessibility of medicines for all people. The private sector is encouraged to use these guidelines and drug list wherever appropriate. Essential medicines are selected with due regard to disease prevalence, evidence on efficacy and safety, and comparative cost. The implementation of the concept of essential medicines is intended to be flexible and adaptable to many different situations. It remains a national responsibility to determine which medicines are regarded as essential. A medicine is included or removed from the list using an evidence based medicine review of safety and effectiveness, followed by consideration of cost and other relevant practice factors. These therapeutic classes have been designated where none of the members of the class offer any significant benefit over the other registered members of the class. It is anticipated that by limiting the listing to a class there is increased competition and hence an improved chance of obtaining the best possible price in the tender process. In circumstances where you encounter such a class always consult the local formulary to identify the example that has been approved for use in your facility. The perspective adopted is that of a competent prescriber practicing in a public sector facility.
Combination therapy allows fidoses fi ficomplications fi Acute rejection: oliguria diabetes symptoms pre diabetes risk factors cheap metformin american express, fiCr diabetes signs n symptoms purchase metformin with american express, fever and swollen graft diabetic diet 2000 buy 500mg metformin with amex. However diabetes insipidus decreased bun buy cheap metformin on-line, this was set using morning samples in young women via catheterisation fi not much value blood glucose monitor reviews purchase line metformin. Renal 219 fi In kids diabetes type 2 gene effective metformin 850mg, a much smaller number may be significant, especially if: fi In a boy fi Obtained by catheter. Bugs can grow in transit fi send to lab straight away or refrigerate fi Antibiotic sensitivity: if multi-resistant then usually from Asia where antibiotics are freely available fi Haematuria in 50% but if asymptomatic fifi For adult women, single does therapy has an odds ratio compared to conventional treatment (5 days or more) of 0. Aggressive but responds to chemo Urinary Incontinence fi Bladder pressure > urethral pressure = flow of urine fi 834% of community dwelling older people. Spontaneous contraction when attempting to inhibit voiding (eg stroke, prostate disease) fi frequency, nocturia, urgency, urge incontinence. In small portion of men with prostate surgery, in women more complex (childbirth trauma, fioestrogen, prolapse etc) fi momentary loss of small volume of urine with fiintra-abdominal pressure (eg cough). Renal 223 Caused by childbirth, surgery, menopause (fiatrophy of urethral epithelium), masses, prolapse, pregnancy, etc fi Overactive sphincter: anticholinergics, neural damage or prostate problems fi retention fi overflow incontinence fi Overflow incontinence: due to over-distended bladder (without detrusor activity) fi Reflex Incontinence: involuntary loss due to abnormal spinal reflex activity without the desire to void fi Assessment: fi History: Screen all elderly people. Impact on function, proximity to toilets, fluid intake, medications, etc fi Exam: neurological, esp. Grossly enlarged can be 500g fi Prostate can become infected, hyperplastic or malignant fi Used to be described in lobes. Now described in zones: fi Anterior zone fi Transition and central zone: main site of benign hyperplasia fi Peripheral zone: main site of malignancy. Suspect post surgery, but still need biopsy Benign Prostatic Nodular Hyperplasia fi Not benign if not treated: fi hydronephros fi kidney failure fi death! Early spread to lymph nodes but doesnfit disseminate widely Scrotum fi Steatocystoma: benign sebaceous cysts, hereditary fi Fournierfis gangrene: Ischaemic necrosis. Treatment: debridement fi Squamous cell carcinoma Testes fi For Torsion and Hydrocoele, see Testes, page 636 Infection fi Epididymo-orchitis: fi Bacterial infection: E Coli, Klebsiella, Proteus fi In adults also Gonorrhoea fi Usually self-limiting fi antibiotics fi Key differential: torsion. Translucent to torch fi Haematocoele: Haemorrhage into tunica vaginalis or tunica albicinia (rugby injury, bleeding disorder) Testicular Tumours fi Incidence 3. Metastasise to inguinal and para-aortic nodes fi Treatment: Orchidectomy via inguinal region (never via scrotum fi different lymphatic drainage. Very responsive to radiotherapy fi Teratoma: fi 30% of testicular tumours fi All can recapitulate ectodermal, mesodermal and endodermal tissue fi Benign teratoma: More common in ovary than testis. Chemo stimulates cells to mature fi still malignant but slower growing fi excision of affected lymph nodes fi Embryonal carcinoma: poorly differentiated, resembles adenocarcinoma. May express tumour marker alpha-fetoprotein fi Choriocarcinoma: Placental tissues (resembles hydatiform mole). Responds well to chemotherapy fi Mixed tumours: Teratoma and seminoma fi Sex chord/stromal tumours: fi Leydig tumours: 90% benign. Present with overproduction of testosterone: precocious puberty or gynaecomastia in post-puberty. Local infiltration fi Lymphoma: Older males, often bilateral, poorly differentiated and poor prognosis fi Testicular tumours present relatively young, lymphoma in older men Differential of Testicular Swelling fi Ref: Casebook 17, July 2002, Medical Protection Society Testicular Torsion Epididymo-orchitis Testicular Caner Pain Acute, sudden onset. Can olds 35, but as young as 15 occur in 20s and 30s History May have had previous Sexual activity. Anatomical position = 0fi fi To finish: fi Special tests fi Joint above and below fi Distal pulses fi Neurology fi Xray and/or aspirate fi Think: acute, chronic, impact on function, systemic effects fi Is it brokenfi If there is a fracture with shortening, there will also be dislocation fi Need to assess rotation relative to joint fi Sometimes need to Xray 2 times. Donfit do it routinely due to fi radiation Describing a fracture fi Which bone fi Site (where on the bone): fi For a femur it can be capital (through the head), subcapital (below the head), transcervical (through the neck), intertrochanteral, supracondylar, at the junction of the proximal and middle thirds, etc fi Diaphysis: mid-portion or shaft of a long bone. Outer cortex and inner medulla fi Epiphysis: Ends of long bones fi Metaphysis: rapidly growing trabecular bone underlying the growth plate Musculo-skeletal 231 fi Type: fi Greenstick: only the convex side of the injured cortex is disrupted, transverse fracture. Can also present as: fi Bowing of a long bone fi Buckle: fracture around the epiphysis if the force was along the axis of the bone fi Transverse: force at 90% to bone ie direct blow (fi also soft tissue injury). Stable when reduced fi Oblique: force at 90% while weight bearing (net vector is oblique). Donfit need big force fi Comminuted (> 2 pieces) fi Epiphyseal: described by Salter-Harris Classification: from I to V (most complex). Big force required fi Stress: fractured bone trying to heal itself and refracturing, etc. May be visible on X-ray, will be visible as a hot spot on bone scan fi Avulsion: ligament tears off bone fi All fractures can also be: fi Pathological fi Simple or compound (bone communicates with air). Described as the distal relative to the proximal portion when in the anatomical position. Medial is varus, lateral is valgus fi Rotation fi Displacement/Translation: are the two ends alignedfi Canfit re-manipulate after this should that be necessary fi Indications for surgery: fi Failure to obtain or maintain closed reduction, or where closed reduction has high failure rate (eg fractured neck of femur) fi Intra-articular fracture (especially if > 1mm displacement after reduction). If no improvement then urgent opinion Musculo-skeletal 233 fi When to start mobilising Complications of Fractures fi Joint stiffness: Cartilage requires motion for nutrition. Need internal fixation and bone grafting fi Non Union: fi Non-union is likely if delayed union is not treated fi Presents as non-painful movement at the fracture site fi Causes: Too large a gap (bone missing, muscle in way), interposition of periosteum fi Clinical: Painless movement at fracture site. Xray shows smooth and sclerosed bone ends or excessive bone formation fi Treatment: Not all cases need treating eg scaphoid, otherwise fixation and bone grafting necessary. Systemic signs of fever fi Treatment: All open fractures require prophylactic antibiotics and excision of devitalised tissue. If acutely infected, surrounding tissues should be opened and drained + antibiotics. Unusual bone alignment, x-ray fi Treatment: fi If detected before union complete angulation may be corrected by wedging of plaster fi Forcible manipulation under anaesthetic fi Osteotomy if union complete and deformity severe fi Compartment Syndrome: fi Elevated pressure in an enclosed space (eg muscle compartment) can irreversibly damage the contents of that space (eg ischaemia) fi Major causes: Processes constricting the compartment or increasing the contents of the space: fi Compressive bandages fi Tight cast fi Haemorrhage and oedema after fracture fi Closure of fascical defects fi Muscles once infarcted are replaced by inelastic fibrous tissue (eg Volkmannfis Ischaemic Contracture of the forearm compartment after humeral supracondylar fracture). Can still have arterial flow through the compartment while muscles are becoming ischaemic fi Signs and symptoms (The 5 pfis i. Symptomatic treatment and protection from stress until healing is complete fi Partial Rupture: If rupture is incomplete, treat conservatively (ranging from rest and analgesia to casting for 6 weeks). Recurrence common fi Complete Rupture: Poor healing as scar tissue is not as tough as the ligament. See Lower Leg and Foot Injury, page 257 Musculo-skeletal 235 fi Can also rupture long head of biceps and supraspinatus fi Other tendon injuries: fi Paratendonitis: Inflammation due to friction of the paratendon (fatty tissue in the fascial compartment through which a tendon runs). May develop blackened shell as blisters burst fi Dry, non-adherent, strictly aseptic dressings and prevention of further trauma (tissues are numb) fi Recovery takes weeks. However, muscle divided transversely will not hold sutures well enough to stop muscular contraction pulling the edges apart Enthesitis fi Inflammation at the site of attachment of bone to a tendon, ligament or joint capsule fi Elbow: See Tennis and Golferfis Elbow, page 246. Steroid injection if severe fi Plantar Fasciitis: fi Insertion of the tendon into the calcaneum fi Pain on standing and walking fi Is isolated, or with sero-negative arthritis fi Treatment: heel pads, reduced walking, steroid injection Chronic Compartment Syndrome fi Caused by fi tissue pressure in a closed fascial space fi fi circulation to muscles and nerves fi Presentation: pain or deep ache over compartment. No recovery without surgical repair fi Mechanisms: Division, stretching, crushing, ischaemia alone or in combination fi Common sites: fi Upper Limb: fi Median nerve: hand through window fi Ulnar nerve at elbow: fracture or pressure fi Radial nerve: cuts around the elbow fi Digital nerve: finger cuts fi Brachial plexus: Downward pressure at the shoulder damages the upper cord, upward pressure damages lower cord fi Cervical nerve roots: compression of vertebrae fi Lower Limb: fi Common peroneal nerve: damage at the neck of the fibula fi Lumbar nerve roots: prolapsed discs fi Sciatic nerve: hip dislocation fi Management: fi Immediate primary suture: if clean cut fi Secondary suture: Clean and debride then suture two weeks later fi Cable Grafts: if long area of damage: graft from another nerve Back and Neck fi Spondylosis = degenerative fi Spondylitis = inflammatory History fi Onset fi Where is it situated fi Sudden or gradual fi Radiation fi Aggravated by movement, coughing or straining fi Effect of rest fi If musculoskeletal then usually well localised and aggravated by movement fi If progressive and unremitting consider osteoporosis (with crush fractures), osteomalacia, or neoplasia (secondaries, leukaemia or myeloma) fi General health, weight loss, fever, sphincter disturbance Exam Inspection fi Look at belt line: is the pelvis horizontal. Place forearm against shoulder and fingers on forehead to stop them tensing when you push on the spine. Look for scoliosis, eg from trauma, developmental abnormalities, vertebral body disease (eg rickets, Tb) or muscle abnormalities (eg polio) fi Feel each vertebral body for tenderness and palpate for muscle spasm fi Gently tap spine with closed fist: severe localised tenderness suggest infection/tumour/trauma fi do xray fi Movement: fi Flexion (touch toes), extension, lateral bending (slide hand down side of leg as far as possible without bending forward) fi Rotation: sit on stool (fixes pelvis) and rotate each direction fi Schoberfis Test: for lumbar flexion. Facet joint dislocation only occurs in association with severe damage to vertebrae fi Soft tissue: disruption of shadows fi Non-traumatic injuries very rarely have positive findings on plain X-ray Neck and Radiating Arm Pain Cervical Spondylosis fi Spondylosis is the most common disorder of the cervical spine. Posteriorly, these may encroach upon the intervertebral foramina, causing pressure on the nerve roots fi Clinical features: fi Neck pain and stiffness, usually gradual onset and worse on getting up fi Pain may radiate widely, to occiput, scapular muscles and down one or both arms fi May be paraesthesia, weakness and clumsiness fi Weakness of the legs or bladder disturbance suggest cervical cord compression fi the appearance is normal. Tenderness occurs in the posterior neck muscles and scapular region, all movements are limited and painful fi Differential Diagnosis: fi Thoracic Outlet Syndrome: pain in the ulnar forearms and hand fi Carpal Tunnel Syndrome: pain and paraesthesia are worse at night. Nerve conduction is slowed across the wrist fi Rotator cuff lesions: pain is like one of a prolapsed cervical disc, but shoulder movements are abnormal and there are no neurological signs th th 238 4 and 5 Year Notes fi Cervical tumours: Symptoms are not intermittent and x-ray may be abnormal fi X-ray: Cervical disc spaces are narrowed. Oblique views may show encroachment of the intervertebral foramina fi Treatment: fi Heat and massage are soothing fi Neck collar is the most effective treatment during painful attacks fi Physiotherapy fi Operation is seldom indicated but if necessary then anterior fusion is appropriate Prolapsed Cervical Disc fi May be precipitated by local strain or injury, esp. Often unaffected by position of spine fi Pain of spinal origin: Upper lumbar refers to groin or anterior thighs. Lower lumbar refers to buttocks, posterior thighs or calves/feet fi Radicular back pain: sharp and radiates from spine to leg in territory of nerve root. Coughing, sneezing or voluntary contraction of abdominal muscles often elicits radiating pain. Mainly in legs, Worst in the legs: pain May spread to May spread to may be some in heaviness/aching buttocks or legs buttocks or legs the back Pattern Intermittent or Always Usually constant Intermittent, varying intensity intermittent occurs with activity Pain worse Sitting, bending Bending Sitting and Worse with with: forward backwards, bending, and by activity standing/walking backwards for long periods movement if acute Pain better Bending Bending forward Lying face down, Bending forward, with backwards, or on back with sitting walking better legs drawn up than standing better than sitting Exercises Face down, push Lie on back, Lie on back on Sit ups to up with hands knees to chest. Pain worse bending backwards fi Presentation: midline pain radiating to groin or buttock, worse towards the end of the day, aggravated by coughing or sneezing. Straight leg raising is normal fi Treatment: analgesics, physio, spinal fusion fi Acute lumbar disc prolapse: fi Nucleus pulposis extrudes into a fissure in the annulus and bulges beneath the posterior longitudinal ligament: fi Pressure on ligament fi back ache fi Pressure on dural envelope of the nerve root fi pain referred to lower limbs (sciatica) fi Compression of nerve root fi paraesthesia and muscle weakness fi Posture: stand forwards and sideways tilt fi Sudden onset lasting for hours/days. Local tenderness and loss of spinal mobility fi Differential: fi Inflammation (eg due to Ankylosing Spondylitis or Tb) fi Vertebral tumours fi constant pain fi Nerve tumours cause sciatic but constant pain fi X-ray to exclude bone disease. Due to fi blood flow to the cauda equina (whose metabolic needs fi on walking) fi Differential of vascular and neurogenic claudication: Activity Vascular Claudication (no foot Neurogenic claudication pulse) Walking Distal fi proximal pain, calf pain Proximal fi distal pain, thigh pain, symmetrical, tingling nerve pain Uphill walking Symptoms develop sooner Symptoms develop later (leaning forward opens facet joints fifiblood flow) Rest Relief with standing Relief when sitting or bending Bicycling Symptoms develop Symptoms do not develop Lying flat Relief May exacerbate symptoms Treatment: Vascular bypass Usually have foot pulses. Conservative treatment fi Osteoporotic: painless or agonising localised pain that radiates around ribs and abdomen. Caution with spine physio: mechanical lever arm forces on vertebrae are very strong fi easy damage fi Psychogenic pain is a contributing factor in some. Look for signs of secondary gain Localisation of Lumbar Root Nerve Entrapment Nerve Root Usual prolapse Sensory Changes Reflex Loss Weakness L2 L2/L3 Front of thigh None Hip flexor and adductors L3 L2/L3 Inner thigh & knee Knee Knee extension L4 L4/L5 Inner calf Knee Knee extension L5 L4/L5 Outer calf, upper None Inversion, dorsiflexion inner foot of toes S1 L5/S1 Lateral borders/ sole Ankle Plantar flexion of foot Red Flags fi Continuous or progressive pain which doesnfit change with movement fi Fever. Hemipelvis is unstable fi If >1 fracture then pelvic ring is unstable and up to 25% will have internal injuries. Good test of glenohumeral joint (eg for frozen shoulder) fi Internal rotation: Test actively: place hand behind back and scratch as high as they can. May be due to osteophytes or narrowing under the coraco-acromial arch fi With age or injury the tendons of these muscles are prone to hyaline degeneration, fibrosis and calcification fi friction, swelling and pain. External rotation causes apprehension fi Fracture of Clavicle: fi Mechanism: fall on outstretched hand fi Clinical: arm clasped to chest to prevent movement, subcutaneous lump fi Xray: usually middle third fi Treatment: support arm in sling until pain subsides (2-3 weeks) fi A/C Joint: fi Mechanism: usually involves fall in which patient rolls on shoulder fi Clinical: Outer end of clavicle prominent, local tenderness present. Confirm subluxation by supporting elbow and detecting movement of clavicle downwards. In serious injuries all three of these areas can be damaged fi Treatment: Broad arm sling for 4-6 weeks usually sufficient fi Infantile Torticolis: Two types fi Congenital shortening of sterno-mastoid muscle fi Neurological: damage to the spinal accessory nerve from infected lymph nodes in the posterior triangle fi Brachial Plexus injury: fi Erbfis Palsy: C5, C6: paralysis of deltoid, supraspinatus, teres major, biceps fi Porterfis tip position fi Klumpkefis Paralysis: C8, T1: arm in adduction, paralysis of small muscles of the hand. Begin mobilising early as pain permits: gentle arm swinging, climbing fingers up the wall. Arm is blue, there is no radial pulse and passive finger extension is painful (the key sign) fi Cast in < 90fi flexion fi Fractured Head of Radius: fi Mechanism: fall on outstretched hand forces elbow into valgus.
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