Fildena

Marc E. Stone, MD

• Associate Professor of Anesthesiology
• Program Director, Fellowship in Cardiothoracic Anesthesiology
• Mount Sinai School of Medicine
• New York, New York

Important Definitions Regulation Definitions the medical examiner should become familiar with frequently used terms in the context of the Federal Motor Carrier Safety Regulations and the medical examiner role erectile dysfunction drugs available in india buy 50 mg fildena overnight delivery. Has a gross vehicle weight rating or gross combination weight rating erectile dysfunction medication natural discount 25mg fildena, or gross vehicle weight or gross combination weight erectile dysfunction treatment at home generic fildena 50 mg, of 4 impotence hernia buy fildena canada,536 kg (10 erectile dysfunction treatment needles purchase cheapest fildena,001 pounds) or more erectile dysfunction protocol amino acids buy on line fildena, whichever is greater; or 2. Is designed or used to transport more than 8 passengers (including the driver) for compensation; or 3. Is designed or used to transport more than 15 passengers, including the driver, and is not used to transport passengers for compensation; or 4. Is used in transporting material found by the Secretary of Transportation to be hazardous under 49 U. Interstate Commerce: Interstate commerce means trade, traffic, or transportation in the United States: 1. Between a place in a State and a place outside of such State (including a place outside of the United States); Page 14 of 260 2. Between two places in a State through another State or a place outside of the United States; or 3. Between two places in a State as part of trade, traffic, or transportation originating or terminating outside the State or the United States. Intrastate Commerce: Intrastate commerce means any trade, traffic, or transportation in any State which is not described in the term "interstate commerce. The term includes, but is not limited to , doctors of medicine and osteopathy, advanced practice nurses, physician assistants and chiropractors. Motor Carrier: Motor carrier means a for-hire motor carrier or a private motor carrier. For purposes of subchapter B, this definition includes the terms "employer" and "exempt motor carrier. The Omnibus Transportation Employee Testing Act of 1991 requires drug and alcohol testing of safety sensitive transportation employees in aviation, trucking, railroads, mass transit, pipelines, and other transportation industries. There are times when a medical examiner may have interactions with healthcare professionals who perform services in the drug and alcohol testing program. A safety risk in any one or more of these commercial operations components can endanger the safety and health of the public. Thus, an estimated 3 to 4 million physical examinations must be performed annually, with the demand increasing every year. Commercial driver medical fitness for duty records must include all Federal physical qualification requirements found on the Medical Examination Report form. Truck and bus companies may also have additional medical requirements, such as a minimum lifting capability. Stat Regulations States regulate intrastate commerce and commercial drivers who are not subject to Federal regulations. They are required, at a minimum, to adopt Federal physical qualification requirements and may even have additional, different, or more stringent requirements. Medical examiners are responsible for knowing the driver regulations for the State or States in which they practice. As a medical examiner, you should be knowledgeable regarding the physical qualification requirements of the driver specified in Subpart E Physical qualifications and examinations. You are responsible for ensuring that only the driver who meets the Federal physical qualification requirements is issued a Medical Examiner?s Certificate. When you issue a Medical Examiner?s Certificate, you are certifying that the driver is medically fit for duty and can perform the driver role that is described in the Medical Examination Form. You may also, at any time, certify the driver for less than 2 years when examination indicates more frequent monitoring is required to ensure medical fitness for duty. The Average Driver the driver population exhibits characteristics similar to the general population, including an aging work force. Aging means a higher risk exists for chronic diseases, fixed deficits, gradual or sudden incapacitation, and the likelihood of comorbidity. All of these can interfere with the ability to drive safely, thus endangering the safety and health of the driver and the public. The Job of Commercial Driving Stress Factors Associated with Commercial Driving Many factors contribute to making commercial driving a stressful occupation. A long relay route requires driving 9 to 11 hours, followed by at least a 10-hour, off-duty period. With a straight through haul or cross-country route, the driver may spend a month on the road, dispatched from one load to the next. The driver usually sleeps in the truck and returns home for only 4 or 5 days before leaving for another extended period on the road. In team operation, drivers share the driving by alternating 5-hour driving periods with 5-hour rest periods. Long hours and extended time away from family and friends may result in a lack of social support. The driver may encounter adverse road, weather, and traffic conditions that cause unavoidable delays. Transporting hazardous materials, including explosives, flammables, and toxics, increases the risk of injury and property damage extending beyond the accident site. Stay alert when driving this demands sustained mental alertness and physical endurance that is not compromised by fatigue or sudden, incapacitating symptoms. Required cognitive skills include problem solving, communication, judgment, and appropriate behavior in both normal and emergency situations. Driving requires the ability to judge the maximum speed at which vehicle control can be maintained under changing traffic, road, and weather conditions. Use side mirrors Mirrors on both sides of the vehicle are used to monitor traffic that can move into the blind spot of the driver. The act of steering can be simulated by offering resistance, while having the driver imitate the motion pattern necessary to turn a 24-inch steering wheel. Use of these components requires adequate reach, prehension, and touch sensation in hands and fingers. This requires the driver to repeatedly perform reciprocal movements of both legs coordinated with right arm and hand movements. Physical demands include grip strength, upper body strength, range of motion, balance, and flexibility. Vision and hearing are used to identify and interpret changes in vehicle performance. When a fatal crash involves at least one large truck, regardless of the cause, the occupants of passenger vehicles are more likely to sustain serious injury or die than the occupants of the large truck. The answer is found in basic physics: injury severity equals relative velocity change. The crash of a vehicle having twice the mass with a lighter vehicle equals a six-fold risk of death Page 21 of 260 to persons in the lighter vehicle. In addition to the grievous toll in human life and survivor suffering, the economic cost of these crashes is exceedingly high. As a medical examiner, your fundamental obligation is to establish whether a driver has a disease, disorder, or injury resulting in a higher than acceptable likelihood for gradual or sudden incapacitation or sudden death, thus endangering public safety. As a medical examiner, any time you answer ?yes? to this question, you should not certify the driver as medically fit for duty. Public Safety Consider Safety Implications As you conduct the physical examination to determine if the driver is medically fit to perform the job of commercial driving, you must consider:. Physical condition o Symptoms Does a benign underlying condition with an excellent prognosis have symptoms that interfere with the ability to drive (e. Is the onset of incapacitating symptoms so gradual that the driver is unaware of diminished capabilities, thus adversely impacting safe driving? Nonetheless, you have a responsibility to educate and refer the driver for Page 24 of 260 further evaluation if you suspect an undiagnosed or worsening medical problem. Medical Examination Report Form Overview As a medical examiner, you must perform the driver physical examination and record the findings in accordance with the instructions on the Medical Examination Report form. The purpose of this overview is to familiarize you with the sections and data elements on the Medical Examination Report form, including, but not limited to:. You are encouraged to have a copy of the Medical Examination Report form for reference as you review the remaining topics. As a medical examiner, you are responsible for determining medical fitness for duty and driver certification status. Health History the Driver completes and signs section 2, and the Medical Examiner reviews and adds comments: Figure 5 Medical Examination Report Form: Health History Health History Driver Instructions the driver is instructed to indicate either an affirmative or negative history for each statement in the health history by checking either the "Yes" or "No" box. The driver is also instructed to provide additional information for "Yes" responses, including:. Health History Driver Signature Verify that the Driver signs Medical Examination Report Form: Figure 6 Medical Examination Report Form: Driver Signature Page 27 of 260 By signing the Medical Examination Report form, the driver:. Regulations You must review and discuss with the driver any "Yes" answers For each "Yes" answer:. As needed, you should also educate the driver regarding drug interactions with other prescription and nonprescription drugs and alcohol. Page 28 of 260 Health History (Column 1) Overview In addition to the guidance provided in the section above, directions specific to each category in Column 1 for each "Yes" answer are listed below. Any illness or injury in the last 5 years A driver must report any condition for which he/she is currently under treatment. The driver is also asked to report any illness/injury he/she has sustained within the last 5 years, whether or not currently under treatment. Seizures, epilepsy Ask questions to ascertain whether the driver has a diagnosis of epilepsy (two or more unprovoked seizures), or whether the driver has had one seizure. Gather information regarding type of seizure, duration, frequency of seizure activity, and date of last seizure. Eye disorders or impaired vision (except corrective lenses) Ask about changes in vision, diagnosis of eye disorder, and diagnoses commonly associated with secondary eye changes that interfere with driving. Complaints of glare or near-crashes are driver responses that may be the first warning signs of an eye disorder that interferes with safe driving. Ear disorders, loss of hearing or balance Ask about changes in hearing, ringing in the ears, difficulties with balance, or dizziness. Loss of balance while performing nondriving tasks can lead to serious injury of the driver. Obtain heart surgery information, including such pertinent operative reports as copies of the original cardiac catheterization report, Page 29 of 260 stress tests, worksheets, and original tracings, as needed, to adequately assess medical fitness for duty. High blood pressure Ask about the history, diagnosis, and treatment of hypertension. In addition, talk with the driver about his/her response to prescribed medications. The likelihood increases, however, when there is target organ damage, particularly cerebral vascular disease. As a medical examiner, though, you are concerned with the blood pressure response to treatment, and whether the driver is free of any effects or side effects that could impair job performance. Muscular disease Ask the driver about history, diagnosis, and treatment of musculoskeletal conditions, such as rheumatic, arthritic, orthopedic, and neuromuscular diseases. Does the diagnosis indicate that the driver is at risk for sudden, incapacitating episodes of muscle weakness, ataxia, paresthesia, hypotonia, or pain? However, most commercial drivers are not short of breath while driving their vehicles. Health History (Column 2) Overview In addition to the guidance provided in the section above, directions specific to each category in Column 2 are listed below for each "Yes" answer. Feel free to ask other questions to help you gather sufficient information to make your qualification/disqualification decision. Lung disease, emphysema, asthma, chronic bronchitis Ask about emergency room visits, hospitalizations, supplemental use of oxygen, use of inhalers and other medications, risk of exposure to allergens, etc. Even the slightest impairment in respiratory function under emergency conditions (when greater oxygen supply is necessary for performance) may be detrimental to safe driving. Page 30 of 260 Kidney disease, dialysis Ask about the degree and stability of renal impairment, ability to maintain treatment schedules, and the presence and status of any co-existing diseases. Digestive problems Refer to the guidance found in Regulations You must review and discuss with the driver any "Yes" answers. Diabetes or elevated blood glucose controlled by diet, pills, or insulin Ask about treatment, whether by diet, oral medications, Byetta, or insulin. To do so, the medical examiner must complete the examination and check the following boxes:. Meets standards but periodic monitoring required due to (write in: insulin treatment. Loss of or altered consciousness Loss of consciousness while driving endangers the driver and the public. Your discussion with the driver should include cause, duration, initial treatment, and any evidence of recurrence or prior episodes of loss of or altered consciousness. You may, on a case-by-case basis, obtain additional tests and/or consultation to adequately assess driver medical fitness for duty. Health History (Column 3) Overview In addition to the guidance provided in the section above, directions specific to each category in Column 3 are listed below for each "Yes" answer. Fainting, dizziness Note whether the driver checked ?Yes? due to fainting or dizziness. Ask about episode characteristics, including frequency, factors leading to and surrounding an episode, and any associated neurologic symptoms (e. Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring Ask the driver about sleep disorders. Also ask about such symptoms as daytime sleepiness, loud snoring, or pauses in breathing while asleep. Page 31 of 260 Stroke or paralysis Note any residual paresthesia, sensory deficit, or weakness as a result of stroke and consider both time and risk for seizure.

Weaning is the journey between when your child is fully breastfed (or If you need or want to actively wean before it happens on its breastmilk-fed erectile dysfunction medicine in ayurveda purchase 50mg fildena amex, if you feed expressed milk) and when your child own erectile dysfunction drugs walmart buy fildena 25 mg amex, it is best for you and your child to go slowly erectile dysfunction treatment honey fildena 50mg without prescription. If you have been advised to stop pressure to wean erectile dysfunction doctor seattle purchase fildena american express, children usually stop Breastfeeding is good for mother and breastfeeding because you need surgery breastfeeding or receiving their mother?s child at any age erectile dysfunction doctor san jose order fildena 150 mg amex, and no evidence has or you take a certain medicine drinking causes erectile dysfunction cheap generic fildena canada, be sure to milk between 2? In most cases, you weaning happens very gradually, often You may also want to consider delaying can still breastfeed after surgery, and without any fuss, process, or efort. The American Academy of Pediatrics baby will need extra comfort during recommends: these times. After 6 months of age, continue to major change, like moving or if you also can call the Ofce on Women?s breastfeed and begin to add solid recently went back to work and your Health Helpline at 800-994-9662, Monday foods (this is when weaning begins. If your continue to breastfeed for as long baby is resisting all your attempts Also, try not to make the decision to wean as both you and your baby are to wean, it may just not be the right on a day when breastfeeding is difcult. If you can, wait and try again in babies continue to nurse into another month or two. For these If your baby suddenly rejects your breast, Nursing sessions get further apart, even babies, weaning from the breast may it is more likely a nursing strike, not a to the point of happening once a day, or, not be difcult, but their nutritional and readiness to wean. Read more about as time goes on, once every few days or a emotional needs will remain. Because your breastmilk changes to meet your baby?s needs as he gets older, he gets the nutrition he needs from the same number of ounces at 9 months as at 3 months old. A breastmilk-fed baby who is weaned to formula may need more ounces of formula than breastmilk. Talk to your child?s doctor to fnd out how much formula your baby needs and how to recognize signs that your baby is tolerating the formula well. Chill the cabbage leaves and wash When you pump or nurse, your Give your baby lots of extra love and before using. If your baby is older Even when you wean slowly and female hormone) that can decrease than 1 year, you can stop ofering the gradually, it may still be uncomfortable your milk supply. This hormonal birth control may also that come before falling asleep or help reduce milk supply. You can note how long the baby If you are feeding pumped breastmilk, include the amount fed at each breast. Wood received his medical degree from the University of Minnesota Medical Please send your questions or comments to: School and completed a general surgery residency Tr e a t i n g C l e f t s i n O l d e r C h i l d r e n : A Pediatric Perspective at Hennepin County Medical Center in Minneapolis. Anna Bittner countries such as Guatemala, China, South Korea, Russia and As the box on Page 2 shows, surgical treatment for from the University of Minnesota. In 2008, Minnesota reported the highest proportion of children born with clefts in the U. She completed a surgery fellowship at involve children who have mild to severe craniofacial anomalies. Clefts are more prevalent in children of Asian, Latino surgical treatment at a later age. It will highlight some of the problems beyond cosmetic initial lip-repair surgery in the country of birth. This course offers assessment tools to help primary-care providers determine master?s degree with a focus on advanced practice hearing loss, speech and language delays, and dental issues. The course also helps providers determine Planning Treatment for Children With Clefts they arrive in the U. It is critical that a craniofacial team assess newly adopted children Center for Cerebral Palsy 651-290-8712 who have clefts even if the children have received treatment in Presurgical Treatment Kelly Nett Cordero, Ph. When teaches introductory skills for analyzing gait and planning associated treatments. Although clefts generally are isolated cleft-lip treatment begins immediately after birth, use Gillette Lifetime 651-636-9443 the advanced track is tailored to clinicians who have experience in gait analysis. At the University of Minnesota, Collier received his doctorate providers and pediatricians assess growth and development (giving Pin-Retention Procedure of dental surgery degree and completed a pediatric Full brochures with additional conference information are available consideration to the cleft) and plan additional care. Speech Services for Spanish-English Bilinguals With cheiloplasty (a lip-augmentation procedure. In addition to velopharyngeal dysfunction, missing teeth and dental Paper presented at the annual meeting of the American Cleft Palate Craniofacial dental problems affect speech, chewing and Association, Philadelphia, Pa. The objective is to create a dental arch similar to that found in Future procedures might include conducting nasometry alignment issues are frequently present in children with clefts. An orthodontist in a surgically; creating a pharyngeal flap to improve speech phonemes (such as p, b, t, d, k and g. Although an overnight hospital stay is rarely necessary, language development of the adopted child is their producing some consonant sounds. The International Adoption Project: Population-based patients often experience significant discomfort after the procedure. Children, therefore, might Surveillance of Minnesota Parents Who Adopted Children Internationally. Therefore, providers prescribe a narcotic analgesic for patients to China at 6 to 25 months of age found that 94. Patients typically experience a setback in feeding and the sample developed skills within or above the typical Infants with clefts particularly cleft palates have a higher maxilla in width as well as stimulate the forward ingest a primarily liquid diet after surgery. Trends in International Adoption: Why Should range for English-speakers after two years of English incidence of hearing problems than infants who do not have clefts. Paper presented at the Cleft and Craniofacial Disorders: A Continuum include an infection at the pin sites and the unlikely scenario of exposure. Such interventions delayed, speech outcomes are less favorable and building up frequently in the middle ear, otitis media, and ear prepare the dental arch for the eventual bone-graft Kuehn, D. Coordinate with lip or palate repairs Language Development of Children Adopted From China. American Journal of can help families assess and encourage their child?s Nutrition Speech Language Pathology, 17, 150-160. Lengthen palate (pharyngeal flap) as percentiles for weight and height measurements. As needed palate repair, many children have speech therapy and and social interactions in their country of birth often influence their techniques related to cleft lip and/or U. Issues related to learning a new language Cleft-Palate Repair and Adoptions Per Year. Such an increase in oral-nasal compensatory speech errors developing or prevents such issues Upon adoption, children often experience many new food tastes and children see a pediatrician for a general coupling can allow excessive amounts of air to escape altogether. Such providers might have to deviate from the standard palates will have velopharyngeal incompetence or needs. In such cases, craniofacial surgeons and orthodontists Four to six weeks after palate-repair surgery, children hypernasal speech after surgery and might require a pharyngeal-flap Dental Problems References often perform a pin-retention procedure, fixing a device to the palate undergo speech evaluations and begin speech therapy, procedure at age 4 or 5. Because Cleft Palate: Implications for Managing Other Linguistically Diverse Populations. For example, the word button abscesses; bacterial, viral and fungal infections; and Speech-Language Pathology, 11, 417-433. After that, a surgeon removes phonemes with sounds, generated from the back of the mouth or the part by abnormalities in tooth development, which Adopted Children. Paper presented as part of an American Speech-Language the device and repairs the cleft lip. Children having pin-retention procedures undergo general those without clefts) from outside the U. Some studies show that if surgery for cleft conditions is function well in children with cleft palates. Typical Course of Surgical Treatment Anecdotal reports, however, show that if children learn for Children With Clefts Nicoladis, E. Learning English and Losing Chinese: a new language especially one with a different speech Primary-care providers, pediatricians and/or audiologists should check A Case Study of a Child Adopted From China. At the time of adoption, children with clefts typically fall into the lower Palate repair. Adoptions by Country, Adoptions by State, speech more slowly and/or less accurately than other. Many children adopted with already repaired cleft lips will have in internationally adopted children who the velopharyngeal port to close properly is sometimes including specialized cleft bottles and nipples, bowls, toddler spoons palate-repair surgery within two to three weeks of their first exam in have a diagnosis of cleft lip and/or palate altered even after repair. Repairing the palate helps to optimize We always recommend that, within a week difficult or impossible to separate the oral and nasal and/or drink with such devices. Most adapt well to their new diet, gain a significant amount of health exam, any needed blood work, a through the nose during speech production, resulting in the perception of hypernasality and/or nasal emissions. Palate-repair surgery usually takes place six to eight weeks after lip rapid catch-up growth. In older children, however, surgeons might repair the children, primary-care providers and pediatricians should consider the About 20 to 30 percent of children who have cleft palate first and then the lip. The procedure involves raising a flap of tissue In the cleft area, teeth often erupt in a crooked that forces repositioning of the segments and prepares the lip for which continues as needed. After the initial services, from the posterior pharynx and inserting it into the soft palate. Doing so optimizes the positioning of the and nasendoscopy tests to check for excessive nasal issues can contribute to articulation errors, including use of nasal treatment. Typical and Atypical Language Development premaxilla and allows the lip musculature to continue pulling the resonance (hypernasality); revising the lip or nose phonemes (such as m, n, and ng) in place of pressure, or ?stop,? often have multiple oral problems, including decay; in Infants and Toddlers Adopted From Eastern Europe. Assessment and Intervention for Internationally during the two to three-week period. The muscles responsible for opening the Eustachian tube do not as early as 3 to 4 years of age but typically is of Care conference, St. Speech and Language Issues in the Cleft Palate articulation-error patterns are more difficult to correct. The International Journal of Treatment sound system after a palate repair, negative children?s hearing during the initial health exam, and routinely Bilingualism, 6, 441-454. A speech evaluation four to six weeks after palate repair diagnoses based on such information, but. When a cleft palate is present, the ability of feeding specialists might advise taking along a variety of feeding tools, http://adoption. Cermin finished an advanced graduate residency in Minnesota estimates that 13 percent of its adoption-related referrals orthodontics. Because international adoptions usually take place in the University of Texas Southwestern Medical School. She ment, contact New Patient Services at the course of surgical treatment for those children 7:30 a. Many have care, for children with craniofacial disorders and plastic 317 On Rice Park Event Center or older. Such problems include feeding issues, ear infections, repair before they are adopted internationally. New Patient Services 651-290-8707 appropriate evaluation and intervention strategies. He treats 800-719-4040 (toll-free) Volume 18, Number 1 patients who have various craniofacial anomalies, rehabilitation medicine. Publications At Emory University in Atlanta, he trained in plastic Gillette Children?s Specialty Healthcare A Focus on Children Who Are Adopted Internationally surgery. Paul DeMarchi Women?s Hospital at Harvard School of Dentistry in international adoptions per capita of any state. At Gillette Children?s Specialty Healthcare, Presurgical treatments for children who begin cleft Clinical Gait Analysis: A Focus on Interpretation velopharyngeal dysfunction and other craniofacial a craniofacial team often includes craniofacial surgeons, plastic repairs shortly after birth are less invasive than they Center for Gait and Motion Analysis 651-229-3868 Basic and Advanced Courses conditions that affect speech. Cordero received her surgeons, nurses, otolaryngologists, orthodontists, dentists, are for children who begin repairs when they are Center for Pediatric Neurosciences 651-312-3176 audiologists, speech and language pathologists, feeding specialists, older. Older children who have not undergone bachelor?s degree in communicative disorders from the June 24 26, 2009 University of Wisconsin Madison and her master?s Center for Pediatric Orthopaedics 651-229-1716 pediatricians, and primary-care providers. The basic track More than 150 syndromes include cleft lip or palate in their Center for Spina Bifida 651-229-3878 alveolus into alignment as much as possible. Candidiasis is the leading infection that most dental practitioners will see in clinical practice. Unless diagnosed early and treated aggressively, mucormycosis can be a locally invasive and disfiguring oral and maxillofacial fungal infection. This review includes several oral and maxillofacial fungal infections, including mucormy cosis, candidiasis, aspergillosis, blastomycosis, histoplasmosis, cryptococcosis, and coccidioidomycosis. Patients may present with infections that can be superficial or indicative of a more serious systemic illness. This article focuses on fungal infections that can range from primary (superficial) to disseminated infections that have a high mortality. Included in the review are the most common oral and maxillofacial fungal infections, route of spread, diagnosis, treatment as well the authors have nothing to disclose. Although uncommon in a dental practice setting, one may encounter fungal infections, such as candidiasis, mucormycosis, histoplasmosis, blastomycosis, aspergillosis, cryptococcosis, geotrichosis and coccidioidomycosis. Table 1 is a broader and comprehensive list of potential oral and maxillofacial fungal infections to serve as reference if one encounters an uncommon organism not covered in this article. In its normal form, Candida is not pathogenic and stays in balance such that it cannot progress to cause infection. Typically, Candida infections occur when one of several scenarios happen, including but not limited to , host defenses becoming compromised, a breakdown of the normal skin or mucosal barrier, a disturbance of the host by external factors (such as intake of broad-spectrum antibiotics), or other internal/external risk factors increasing the likelihood of a Candida infection. The Candida species consists of 2 to 6-mm yeastlike organisms that reproduce through budding. The most commonly encountered infection from Candida is oral thrush, also known as pseudomembranous candidiasis.

Punch graft hair transplant may be considered reconstructive when it is performed to correct permanent hair loss that is clearly caused by disease or injury (e erectile dysfunction with diabetes type 1 buy generic fildena line. Otoplasty (ear pinning) for absent or deformed ears such as microtia (small erectile dysfunction red 7 order fildena 50 mg without prescription, abnormally shaped or absent external ears) or anotia (total absence of the external ear and auditory canal) with functional deficiencies resulting from trauma erectile dysfunction papaverine injection purchase fildena now, surgery safe erectile dysfunction pills buy fildena 100 mg overnight delivery, disease or congenital defect when performed to improve hearing by directing sound into the ear canal xyzal impotence buy fildena paypal. Post-mastectomy or post significant lumpectomy resulting in asymmetry: breast reconstruction erectile dysfunction drugs australia order 25mg fildena fast delivery, including nipple reconstruction, tattooing and surgery on contralateral breast to restore symmetry; T. Removal of a breast implant, periprosthetic capsulotomy or capsulectomy for mechanical complications of breast prosthesis such as rupture, extrusion, painful capsular contracture with disfigurement, inflammatory reaction to implant, siliconoma, granuloma, interference with diagnosis of breast cancer U. It is the policy of Health Net of California that cosmetic surgery is not medically necessary and generally not a covered benefit when performed to improve a patient?s normal appearance and self-esteem. Cosmetic surgery performed purely for the purpose of enhancing one?s appearance, and/or expenses incurred in connection with such surgery B. Flesh color tattooing for the treatment of port wine stains, hemangiomas or birth marks F. Septoplasty performed solely to improve the patient?s appearance in the absence of any signs and/or symptoms of functional respiratory abnormalities H. Rhinoplasty for external nasal deformity not due to trauma or disease (non covered services) I. Surgery to correct a condition of ?moon face? which developed as a side effect of cortisone therapy L. Otoplasty (ear pinning) for lop ears, bat ears or prominent or protruding ears without M. Injection of any filling material (collagen) including but not limited to collagen, fat or other autologous or foreign material grafts unless treatment for facial lypodystrophy N. Excision excessive skin, thigh, leg, hip, buttock, arm, forearm or hand, submental fat pad, other areas R. Electrolysis or laser hair removal unless specified (ie gender reassignment surgery) S. Hair transplants to correct male pattern baldness (alopecia) or age related hair thinning in women W. Vermilionectomy (lip shave), with mucosal advancement Background Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, previous or concurrent surgeries, trauma, infection, tumors or disease. It is generally performed to improve the functioning of a body part and may or may not restore a normal appearance. Functional impairment is a health condition in which the normal function of a part of the body or organ system is less than age appropriate at full capacity, such as decreased range of motion, diminished eyesight or hearing, etc. Cosmetic surgery is performed to reshape normal structures of the body in order to improve the appearance and self-esteem of a patient. This policy will provide general guidelines as to when cosmetic and reconstructive surgery is or is not medically necessary. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services. Added references Removed Nasal Surgery (S) and section on pectus excavatum (T) and Nuss 11/19 11/19 procedure (U) from medically necessary section since all have Interqual criteria References 1. National Breast Reconstruction Utilization in the Setting of Postmastectomy Radiotherapy. Breast reconstruction after mastectomy: A ten-year analysis of trends and immediate postoperative outcomes. Important Reminder this clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time. This clinical policy does not constitute medical advice, medical treatment or medical care. Members should consult with their treating physician in connection with diagnosis and treatment decisions. Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members and their representatives agree to be bound by such terms and conditions by providing services to members and/or submitting claims for payment for such services. Note: For Medicaid members, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy. All materials are exclusively owned by Centene Corporation and are protected by United States copyright law and international copyright law. No part of this publication may be reproduced, copied, modified, distributed, displayed, stored in a retrieval system, transmitted in any form or by any means, or otherwise published without the prior written permission of Centene Corporation. You may not alter or remove any trademark, copyright or other notice contained herein. Centene and Centene Corporation are registered trademarks exclusively owned by Centene Corporation. The transition between each constraint level can be made with ease, allowing the physician to evaluate soft tissue and bone defciencies intraoperatively without making a preoperative commitment to the level of constraint. The Vanguard Knee is supported by fve instrumentation platforms: Microplasty?, Premier?, Microplasty? Elite, Vanguard Tensor, and Premier? Anterior Referencing Systems, Figure 2 accommodating a number of workflows and Regenerex Porous Titanium Construct techniques. The Signature System, which fts the femoral and tibial components independently, when. E1? Antioxidant Infused Bearing Technology used with the Vanguard Complete Knee System, ofers. Regenerex? Porous Titanium Construct a comprehensive solution for personalized patient. See page 16 for more information regarding the E1 Antioxidant Infused Bearing Technology Signature System. E1 Antioxidant Infused Tibial Bearing Technology defnes a new class of bearings and overcomes the limitations of remelted and annealed polyethylenes by uniting true oxidative stability, high mechanical strength, and ultra-low wear4,5 (Figure 1. Figure 3 Signature? Personalized Patient Care Figure 1 E1 Antioxidant Infused Tibial Bearing 5 | Vanguard Complete Knee System Design Rationale Femoral Design Features Deeper/Swept-back Trochlear Groove When designing the Vanguard Complete Knee System, the trochlear groove is a critical design feature for every aspect of the femur, tibia, and patella was patella performance. Translation of the trochlear reviewed for potential performance enhancements groove posteriorly in the femur has shown to resist patella crepitus and clunk. Many clinically successful features found in earlier Zimmer Biomet Total Knee the Vanguard trochlear groove has been designed Systems can be found in the Vanguard Complete Knee to sweep back posteriorly for better patellar System. Sizing Rounded Sagittal Profle Two distinct femoral designs have evolved over time Figure 5 (Figure 4): Standard Trochlear Groove (Green) vs. Swept-back (rounder) femoral profle Patellar capture during fexion must be balanced with the need for less patellar constraint in extension. The trochlear foor of the Vanguard Knee has been widened to reduce the constraining forces in extension. Vanguard Swept-back Sagittal Profile (Gray) 0?15? A round sagittal profle, as found in the Vanguard Knee, allows for greater range of motion than anatomic femoral components and may be more forgiving to the retinaculum by not over tensioning the soft tissues. This feature allows for posterior and distal augmentation in a primary total knee arthroplasty or. Femoral sizes increase A/P by an average of the use of a primary component in the revision of a 2. The posterior condyle geometry has also been optimized to provide larger contact areas in deep fexion to dissipate forces on the bearing more efectively. This radius enhancement provides the Vanguard Complete Knee System features increased contact area when the patella articulates optimized tibiofemoral articulation based on the on the condyles in fexion. A Finite Element Analysis enhanced design of the following elements: has demonstrated a 25 percent reduction in patella contact pressure compared to the Maxim? Total Knee4. The 1:1 condylar geometry provides surgical fexibility by allowing complete tibial femoral interchangeability* (Figure 10. Figure 11 Finite Element Analysis Demonstrates a Gradual Dispersion of Forces Along the Patella Sagittal Geometry the Vanguard Knee has been designed to allow up to 145 degrees of fexion without additional posterior condyle resections (Figure 12), with early results showing postoperative mean rage of motion of 125 degrees at three year follow-up. Figure 13 High Flexion Patellar Tendon Relief Curved Articulation To increase contact area with axial rotation, the Vanguard Knee features a rotated articulation bearing surface (Figure 14. Zimmer Biomet?s ability to provide a of the industry?s most advanced bearing technologies. Following Zimmer Biomet?s traditional engineering approach, E1 Antioxidant Infused Technology it was the frst company to use inert gas (argon) to replace oxygen during the sterilization and E1 Antioxidant Infused Tibial Bearing Technology packaging process. The use of argon reduces the defnes a new class of bearings and overcomes the degradative efects of oxygen in polyethylene limitations of remelted and annealed polyethylenes bearings. Gamma12 EtO Sterilized ArCom?Gamma Sterilized Cycles (millions) Figure 16 Wear Testing 10 | Vanguard Complete Knee System Design Rationale E1 Antioxidant Infused Bearings are neither annealed An internal Zimmer Biomet study demonstrated that nor remelted. Peripheral polyethylene thickness is maintained by locating the locking mechanism anteriorly and Figure 23 within the intercondylar area Regenerex? Porous Titanium Technology. Vanguard?s Locking Mechanism compresses the Regenerex material provides for: polyethylene bearing against the tray by utilizing an oversized titanium locking bar that forces the. High strength and fexibility4 Engh, and a study published by Sosa, have shown the Vanguard Locking Mechanism to be ?the. Tibial Tray Design Features Concerns have been raised about modularity and bearing micromotion as a contributor to osteolysis and early failure. Anterior Compressive Locking Mechanism the modular design of the Vanguard Tibial Tray is based on clinically successful features of earlier Zimmer Biomet Total Knee Systems, including:. Stem Options 13 | Vanguard Complete Knee System Design Rationale Sizing Tibial Baseplate Options Many knee systems ofer a variety of tibial tray sizes. Primary tibial trays are made from both titanium However, few systems ofer consistent sizing. The Vanguard Complete Knee System is compatible with the following cobalt chrome baseplate options: I-beam, cruciate fnned, or Microplasty? Tray with an Interlok? Finish (Figure 29. Figure 30 Modular Tibial Tray Stems I-beam Tray Cruciate Finned Tray the combination of a Morse-type taper and screw fxation helps maintain a solid connection between the stem and baseplate. When more fxation is desired, the stemmed or ofset tray will accept a 40, 80, 120, 160, or 200 mm stem extension (Figure 31. Stem Microplasty? Tray extensions are available in splined, smooth and grit Figure 29 blasted fnishes. Bowed, splined, smooth and grit Cobalt Chrome Baseplate Options blasted stem extensions are ofered in 160 and 180 mm lengths. I-beam and cruciate fnned baseplates feature a 40 mm stem design while the 20 mm cruciate stem design of the Microplasty Tibial Tray allows for a less invasive procedure and arcs posteriorly to increase resistance against pull-out. All augments are fxed to the baseplates by bolts, allowing a mechanical lock between the tray and augments. Figure 31 Stem Extensions 15 | Vanguard Complete Knee System Design Rationale Patellar Articulation Regenerex Patella the Vanguard Complete Knee System ofers multiple the Regenerex Primary Three Peg Patella patella options: incorporates Zimmer Biomet?s Regenerex Porous Titanium Construct with the Series A true dome. The Single Peg (1-Peg) octagonal pegs provide for initial fxation on the resurfaced bone (Figure 34. Series A and Regenerex Patella size and thickness ofering listed below (Figure 35): Diameter (mm) Patella Sizing Chart 25 28 31 34 37 40 Series A Low Profle 6. When used G H I with the Vanguard Complete Knee System, it ofers a comprehensive solution for personalized patient care. Signature Positioning Guides Figure 36 Signature Planning Landmarks Signature? Planning Landmarks the Signature System features proprietary planning Signature Total Knee Planning Software algorithms to generate an initial preoperative plan incorporating traditional resection guides and Software built into the Signature System allows allowing intraoperative position verifcation by the surgeons to visualize and specify an implant position surgeon. Automated planning algorithms generate preoperative plan based of mechanical axis A Anterior/Posterior Axis. Positioning guides incorporate preoperative C surgeon alteration Distal Femoral Mechanical Axis D Lateral Distal Femoral Condyle the result of the preoperative surgical planning is a more focused intervention with the instruments E Medial Distal Femoral Condyle required for surgery as well as the operative plan. F Posterior Condylar Axis G Lateral Plateau H Proximal Tibial Mechanical Axis Landmark I Medial Plateau J Medial One-third of the Tibial Tubercle 17 | Vanguard Complete Knee System Design Rationale Signature Positioning Guides Instrumentation Platforms Preoperative surgeon planning is integrated into the Vanguard Complete Knee System is supported Signature Positioning Guides (Figure 37. Premier Anterior Referencing Instrumentation Figure 37 Microplasty Total Knee Instrumentation Signature Positioning Guides Microplasty Total Knee Instrumentation is designed for use with minimally invasive surgical techniques Femoral positioning guides register on femoral and includes Zimmer Biomet?s Slidex Technology bearing to establish: which allows for minimal disruption to soft tissues during total knee arthroplasty (Figure 38. Enhanced Vanguard Tensor is designed to assist in balancing instrument functionality allows for reproducible and soft tissues during total knee arthroplasty (Figure 41. Figure 39 Premier Total Knee Instrumentation Figure 41 Microplasty Elite Total Knee Instrumentation Vanguard Tensor Instrumentation Microplasty Elite Total Knee Instrumentation Premier Anterior Referencing Instrumentation is designed for use with both traditional surgical methods as well as minimally invasive techniques. Anterior Referencing Instrumentation is available for this instrumentation is designed for minimization use with the Vanguard Complete Knee System. This of soft tissue trauma that occurs during total knee instrumentation allows for anterior referencing during arthroplasty (Figure 40. The Vanguard Knee is supported by fve instrumentation platforms: Microplasty, Premier, Microplasty Elite, Vanguard Tensor, and Premier Anterior Referencing Systems, accommodating a number of workfows and techniques. Figure 44 Advanced Technology Regenerex Porous Titanium Construct the Vanguard Complete Knee System continues to Signature Personalized Patient Care advance total knee arthroplasty with innovative technologies to provide personalized patient care. Regenerex Porous Titanium Construct the femoral and tibial components independently. Signature Personalized Patient Care when used with the Vanguard Complete Knee System, ofers a comprehensive solution for personalized E1 Antioxidant Infused Bearing Technology patient care (Figure 45.

Understand the indications for and the contraindications to regional anesthetic techniques including central neuraxis blocks erectile dysfunction vitamin e purchase cheap fildena, peripheral nerve blocks xatral erectile dysfunction buy cheap fildena 150 mg, sympathetic nerve blocks erectile dysfunction statistics race generic 25mg fildena mastercard. Rational selection of regional anesthesia technique and choice of local anesthetic for particular patient encounters erectile dysfunction homeopathic drugs cheap 150 mg fildena free shipping. Ability to assess adequacy of regional anesthesia before the start of surgery erectile dysfunction pills in malaysia discount fildena online mastercard, and demonstrate appropriate plans for supplementation of inadequate blocks impotence at age 70 buy generic fildena 25mg on line. Provide effective anxiolysis and sedation of patients by both pharmacologic and interpersonal techniques. Select appropriate monitors for specific patient encounters, and document performance of regional anesthetic adequately. Final Theory papers: 4 Papers Marks Paper I Basic Sciences as applied to 100 Anaesthesiology, including ethics, statistics, Quality assurance, medicolegal Aspects. Paper 2 Anaesthesia in relation Associated Systemic 100 Paper 3 Anaesthesia in relation to subspecialities such 100 As cardiac, neuro, obstetrics and pediatrics etc. Final Assessment Marks Weightage 30% : Internal (Formative) Assessment & Thesis 70% : Summative Assessment the committee recommends that three external and three internal examiners should conduct the clinical examination. A maximum of 4 candidates should be examined per day and if there are more than 4 candidates the examination should be conducted on 2 consecutive days. The student would be able to demonstrate capability in research by planning and conducting systematic scientific inquiry & data analysis and deriving conclusion. Co-guide(s) will be from the department or from other disciplines related to the thesis. Submission of thesis protocol It should be submitted at the end of six months after admission in the course. Statistician should be consulted at the time of selection of groups, number of cases and method of study. The protocol must be presented in the department of Anaesthesiology before being forwarded to the Research Committee of the Institute. Protocol will be approved by the research committee appointed by the Dean/Principal to scrutinise the thesis protocol in references to its feasibility, statistical validity, ethical aspects, etc. The thesis shall relate to the candidate own work on a specific research problem or a series of clinical case studies in accordance with the approved plan. The thesis shall be written in English, printed or typed on white bond paper 22 × 28 cms with a margin of 3. The thesis shall contain: Introduction, review of literature, material and methods, observations, discussions, conclusion and summary and reference as per index medicus. Each candidate shall submit to the Dean four copies of thesis, through their respective Heads of the Departments, not later than six months prior to the date of commencement of theory examination in the subject. The thesis shall be referred by the University evaluation to the Examiners appointed by the University. The thesis shall be deemed to have been accepted when it has been approved by atleast two external examiners and if the thesis is rejected by one of the external examiners it shall be referred to another external examiner (other than the one appointed for initial evaluation) whose judgement shall be final for purposes of acceptance or otherwise of the thesis. Where improvements have been suggested by two or more of the examiners, the candidate shall be required to re-submit the thesis, after making the requisite improvements, for evaluation. When a thesis is rejected by the examiners, it shall be returned to the candidate who shall have to write it again. The second thesis, as and when submitted shall be treated as a fresh thesis and processed. Acceptance of thesis submitted by the candidate shall be a pre-condition for his/her admission to the written, oral and practical/clinical part of the examination. Provided that under special circumstances if the report from one or more examiners is not received by the time, the Post-graduate examination is due, the candidate may be permitted provisionally to sit for the examination but the result be kept with held till the receipt of the report subject to the condition that if the thesis is rejected then the candidate in addition to writing a fresh thesis, shall have to appear in the entire examination again. A candidate whose thesis stands approved by the examiners but fails in the examination, shall not be required to submit a fresh one if he/she appears in the examination in the same branch on a subsequent occasion. Acquire in depth knowledge of structure of human body from the gross to the molecular level, and correlate it with the functions. Comprehend the principles underlying the structural organization of body and provide anatomical explanations for disturbed functions. Understand critical periods of human growth and development as well as ontogeny of all the or 5gan systems of body. Analyze the congenital malformations, know the etiological factors including genetic mechanisms involved in abnormal development and their effects on functions. Have comprehensive knowledge of the basic structure and correlated function of the nervous system in order to understand altered state in the various disease processes. Be familiar with and be able to use different teaching methods and modern learning resources for under-graduate teaching. Develop/acquire an attitude of scientific enquiry and learn contemporary research techniques. Be familiar with recent scientific advances, identify lacunae in the existing knowledge in a given area and be able to plan investigative procedures for research, analyze data critically and derive logical conclusions. Histological techniques, identification light and electron microscopic structure of tissues of body. Slides, specimens of developmental anatomy, genetics, neuroanatomy to assess comprehensive knowledge in these areas. Viva voce on gross anatomy, living anatomy, sectional anatomy and neuroanatomy, developmental anatomy. Seminars, written assignments, group discussions on selected topics on regional anatomy. Cell Biology: Cytoplasm – Cytoplasmic matrix, cell membrane, cell organelles, cytoskeleton, cell inclusions, cilia and flagella. Tissues of Body: Light and electron microscopic details and structural basis of function, regeneration and degeneration. The systems/organs of body – Cellular organization, light and electron microscopic features, structure function correlations, and cellular organization. Gross features, cytoarchitecture, functions, development and histogenesis of various primary and secondary lymphoid organs in the body. Biological and clinical significance of the major histocompatibility complex of man including its role in transplantation, disease susceptibility/resistance and genetic control of the immune response. Human Chromosomes Structure, number and classification, methods of chromosome preparation, banding patterns. Chromosome abnormalities, Autosomal & Sex chromosomal abnormalities – syndromes, Molecular and Cytogenetics. Single gene pattern inheritance: Autosomal & Sex chromosomal pattern of inheritance, Intermediate pattern and multiple alleles, Mutations, Non Mendelian inheritance, Mitochondrial inheritance, Genomic imprinting, parental disomy. Multifactorial pattern of inheritance: Criteria for multifactorial inheritance, Teratology, Structure of gene, Molecular Screening, Cancer Genetics – Haematological malignancies, Pharmacogenetics. Reproduction Genetics Male and Female Infertility, Abortuses, assisted reproduction, Preimplanation genetics, Prenatal diagnosis, Genetic Counselling, Ethics and Genetics. Discussions on clinical problems related to neurological disorders and anatomical explanation for the same. Applications of knowledge of developmental, micro, neuro anatomy to comprehend deviations from normal. Recent advances in medical sciences which facilitate comprehension of structure function correlations and applications in clinical problem solving. Grays Anatomy Williams et al 38th edition, 1995 reprint in 2000 Churchill Livingstone 2. This includes molecular motif of a living cell, structural and functional hierarchy of biomolecules and their structure-function relationships. Biochemistry of human nutrition, metabolism, metabolic interrelationships, metabolic homeostasis, molecular and cell biology, body defense against xenobiotics and pathogens, principles of various laboratory estimations, instrumentations and rationale underlying biochemical laboratory investigations. Conduct Biochemical laboratory investigations and experimentations relevant to clinical management and biomedical research. Plan & conduct lecture, practical demonstrations, tutorial classes and small group discussions on clinical problems for undergraduates students of medical and allied disciplines. Prepare research protocols, conduct experimental studies analyze and solve clinical and experimental problems. Post graduate lectures, tutorials, seminars: To update on various aspects of basic and clinical biochemistry & impact of molecular biology on advances in medicines. Journal club: To develop (a) skills of analysis, evaluation and presentation of research papers (b) familiarity with approaches and methodologies of research and (c) to update on new development/emerging trends in biochemistry. The acceptance of the thesis will be a prerequisite for the candidate to be allowed to appear in the final exam. Specialized training in Clinical Biochemistry: 2 months posting in the clinical biochemistry laboratory to learn sample collection, quality control methods, setting up of a clinical biochemistry laboratory, specialized assays, statistical analysis of data. General Biochemistry: Cell structure, its biochemical make up and functions, membrane structure and functions, cytoskeleton, structure and functions of proteins, muscle and plasma proteins, hemoglobin, biochemistry of blood clotting, body fluids and their importance in clinical biochemistry. Enzymes: Principles and mechanisms of enzymatic catalysis, enzyme kinetics and regulation of enzyme activity. Biostatistics and research methodology, their application in research and clinical chemistry, types of study designs, data analysis, correlation & agreement analysis methods, risk analysis methods, calculation of adequate sample size for various study designs, students t test, paired t test, chi-square test and Fishers exact test, Non-parametric tests of significance, Statistical aspects of diagnostic tests, Multivariate analysis methods, One way and two way analysis of variance and multiple range tests, Commonly used statistical software for the analysis of bio-medical data. Bioenergetics and intermediary metabolism: Metabolism of carbohydrates, lipids, proteins, amino acids, porphyrins, purines, pyrimidines, their regulation dysregulation and inter-relationships. Principles of bioenergetics, electron transport chain and oxidative phosphorylation. Vitamins: Fat and water soluble vitamins their chemistry action functions and deficiency. Hormones: chemistry, mechanism of action and their role in regulation of metabolism and physiological functions consequence of hormonal dysfunction. Immunology: Structure functions, classifications and synthesis of immunoglobulins, antigen-antibody reaction, mechanisms and regulation of immune responses. Complement system, hypersensitivity, immune tolerance, immunity to infection, autoimmunity & auto immune diseases, tumor immunity, genetics of immune response, transplantation, experimental system used in immunology, vaccination and immunization strategies, hybridoma technology. The students undergo training in an environment of advanced research in various aspects biophysics. They receive a sound theoretical knowledge coupled with a demanding practical application. By the end of the course, the student is confident to discuss and dissect any aspect biophysical problem related to clinical sciences. Practical Examination One experiment in any of the biophysical techniques taught one day 3. Viva voce Examination Thesis presentation Bench Viva voce General Viva voce the detailed curriculum to achieve the above objectives is detailed below. It contains four sections of theoretical course and one section of practical course. Besides these, the students require to complete a thesis in any of the research activities of the faculty. To help in acquiring theoretical knowledge, additional resources are indicated in appendix – 1. Mode of action of drugs, quantitative structure-activity relationship, present and future aids to drug-design. Hormones and Drugs Structure and conformation of drugs and receptors, drug-receptor binding forces, haemoglobin as a model receptor, steroid conformation, receptor binding and hormone action, structural aspects of drug nucleic acid interactions. Principles and instrumentation of electron spin resonance, spin hamiltonian and its use to study biomolecules, spin probes and their uses, principles of Mossbauer spectroscopy, quadrupole splitting, isomer chemical shift and magnetic hyperfine splitting, applications of Mossbauer spectroscopy in medicine and biology. Electron Microscopy Basic principles, procedures and applications in biology and medicine. X-Ray Diffraction Techniques Methods of recording the X-ray diffraction patterns: rotation method, Weissenberg method, precession method, precession rotation method and diffractometer methods. Methods of protein structure analysis, crystallization of proteins, symmetry in molecules and crystals, Principle of X-ray diffraction, isomorphous replacement, molecular replacement method. Separation Techniques Basic principles and application of electrophoresis, centrifugation and chromatography. Molecular Modelling Basic principle of modeling, Modeling by energy minimization technique, Concept of rotation about bonds, Energy minimization basic technique for samll molecules. Protein Structure and Function Nature and function of globular proteins, basic principle of protein structure, amino acids, peptide structure, secondary structure of polypeptides and proteins, tertiary structures of haemoglobin, myoglobin, trypsinogen, trypsin, collagen and membrane proteins, interactions of proteins with small molecules and ions. Lipids Structure of lipids, phase changes in lipids, their role in pathogenesis of atherosclerosis, gall stone formation, structure of membranes, membrane receptors, transport across membranes. Contractile proteins Role of contractile proteins in cell function and muscle contraction. Use of imaging devices and external detectors for organ imaging; time dependent and differential functional studies, use of physiological gating techniques for functional studies, methodology and quality control of competitive binding and radio immunoassay, procedures for the measurement of peptide hormones, drugs and other biological substances, basic principles of radionuclide therapy in thyrotoxicosis, carcinoma of thyroid. Single crystal X-ray diffraction patterns from protein crystals using precession method. To simulate alpha helix/beta sheet of protein with given sequences and determine specified angles and distances. An approval of the thesis is essential for the candidate to take the final examination. Aim of postgraduate training is to prepare the students to be – – Teachers – Researchers & Epidemiologists – Health Planners, Organizers and Administrators – Workers in the Community – Other service Personnel in this specialty Towards this end, by the completion of his/her training, the Postgraduate student be : 1. Aware of physical, social, psychological, economic and environmental aspects of health and disease in individual, family and community. Able to apply the clinical skills to recognize and manage common health problems including their physical, emotional, social and economic aspects at the individual and family levels 3. Able to identify, plan and manage the health problems of the community he/she serves. For this, he/she should be able to design a study, collect date, analyse it with appropriate statistical tests and make a report. Identify the health needs and health demands of the community and prioritise the most important problems and help formulate a plan of action to manage them under National Health Programmes guidelines including population control and family welfare programme. He/she should be able to assess and allocate resources, implement and evaluate the programmes. Demonstrate ability of organizing prevention and control of communicable and non-communicable diseases.

Slow jogging is introduced gradually; walking is increased to jogging erectile dysfunction protocol food lists purchase fildena 150mg amex, then jogging is alternated with walking and speed is increased impotence 10 buy generic fildena from india. Beginning on the fourth or fifth day after most long flights erectile dysfunction for young males buy fildena visa, carbonate (Narzan) baths are given every other day for 10–15 sessions impotence lexapro 25 mg fildena free shipping. These baths have positive effects on the nervous and cardiovascular systems; contraindications include infections erectile dysfunction vacuum pump india best order fildena, skin diseases erectile dysfunction lexapro cheapest fildena, and acute cardiac ailments. Therapeutic exercises in the water and gymnasium, graded walking, and baths are scheduled throughout the day in order to avoid excessive fatigue, both in general and for specific systems, especially the cardiovascular and neuromuscular systems. Exercises and swimming in the pool are scheduled 2 hours after morning calisthenics and no sooner than 1–1. During the early stages of readaptation, the interval between therapeutic exercise and bath must be at least 2 hours. Physiological-system functions generally recover by the end of the second week of rehabilitation. However, isolated symptoms of asthenia may remain, with hematological and biochemical shifts reflective of the functioning of the musculoskeletal system. Coordination often has not recovered fully, and muscle strength and reaction time often are still diminished, as are endurance and performance capacity. The health resorts of the Northern Caucasus offer a unique combination of natural therapeutic factors. The location of the health-spa complex, between two seas bordering subtropical and steppe climatic zones, ensures sunny weather throughout the year, and the proximity of the subtropics and Black Sea are conducive to warm weather. Mean annual temperatures in the Crimea are comfortable, relative humidity is moderate (mean of 65%), and the sun shines 48 for 2100– 2400 hours per year. The propitious combination of environmental factors—mild climate, warm sea, proximity of picturesque mountains covered with forests, rich park-like vegetation, and therapeutic mineral water and mud—endows the Crimea with exceptionally favorable conditions for postflight rehabilitation. The Kislovodsk health spa leads other nearby health resorts in terms of the amount of sunshine (300 sunny days a year), moderate altitude (1000 m above sea level), pure, dry air, absence of fog, and unique terrain. Kislovodsk also is the source of the Narzan mineral waters, long known to the local population as possessing curative and 49 invigorative properties. The curative properties of Narzan—a mineral water of the carbonate-hydrocarbonate sulfate-calcium type—stem from its high concentration of carbon dioxide and the presence of ions of iron, manganese, zinc, copper, aluminum, and other trace elements. In addition to its climate, Kislovodsks altitude also beneficially affects the recovery process. Adaptation to the relative hypoxia at high altitudes (where oxygen partial pressure is less than at sea level) increases the oxygen capacity of the blood and numbers of blood cells, expands the numbers of capillaries in the brain and heart, and 49 50,51 increases nonspecific immunological resistance. Several authors consider these adaptations to hypoxia to be the opposite of the reactions to hypodynamia and analogous to reactions to physical training. During the sanatorium-health spa phase of rehabilitation, rehabilitative and remedial measures initially follow a restricted-training regimen, which later is replaced by the training regimen. Rehabilitative measures make optimal use of the climate and the health-spa facilities, and include physical factors of rehabilitation and mineral baths. Climatotherapy is prescribed only when weather conditions are favorable, and is strictly regulated in accordance with the cosmonauts tolerance of cold. Aerotherapy facilitates conditioning of cosmonauts thermal-adaptation mechanisms, stimulates oxidative processes in the body, and increases enzymatic activity. Types of aerotherapy used include graded exposure to fresh air, sleeping on the seashore, and air baths. Swimming in the sea is regulated with respect to exposure to cold: only dips are permitted at first, followed by short periods of sea-bathing, the length of which are increased every 2 to 4 days. Morning calisthenics involve 20–25 exercises that focus on enhancing strength, endurance, speed, and coordination. These execises are combined with sports and rapid running to total 25-minute sessions. First, exercises that build strength, in contrast to endurance, increase muscle-fiber mass through thickening existing muscle fibers (hypertrophy. Second, physical exercise enhances the blood supply to skeletal muscles by opening potential collaterals and by increasing the number of capillaries in the 59 muscles. Increases in capillary density are not associated with muscle-fiber hypertrophy; indeed, strength training 60 (which does induce hypertrophy) has been shown to decrease capillary density. Third, different forms of physical exercise induce different respiratory reactions. During static loading (strength training), increases in pulmonary ventilation, oxygen consumption, and carbon dioxide emission are not great, and tend to peak after the exercise session terminates. This reaction, known as the Lindgart phenomenon, reflects the fact that static loading disrupts and delays the rhythm of respiration. As a result, coordination between ventilation and blood supply to the lungs is 61 disrupted, and hypercapnia and hypoxia develop, leading to hyperventilation after exercise. Vital (respiratory) capacity typically does not change in strength training; however, vital capacity can be increased greatly by endurance training. Fourth, 65,66 endurance training increases the maximal level and stability of cardiac contractility. Endurance training leads to increases in 68 the numbers of capillaries in cardiac muscle (as well as in skeletal muscle) and enlarges their diameters. For these reasons, cyclic endurance exercises like graded walking on various terrains and swimming are included in the postflight rehabilitation program. Four Terrainkur routes are available, each having different angles of ascent and distance. For Route 1, the angle of ascent ranges from 0° to 5°, and distance is up to 500 m. Route 2 angles of ascent are between 5° to 10°, and distance is 1000 m; Route 3 angles are 10° to 15°, and distance is 2000 m; Route 4 angles are 15° to 20°, and distances are 3000–5000 m. During the recovery process, the Terrainkur routes prescribed for the cosmonauts gradually are made more difficult with respect to steepness, distance, speed, and duration of rest periods. Use of the Terrainkur fosters tolerance of increased physical loading, since walking up an incline of 2 to 20° at a moderate speed is a typical endurance exercise. Water or snow skiing are used extensively, depending on the time of year and location of the health spa. Recommended balneotherapies involve contrast baths in various media, which have a tonic effect on the autonomic 45 nervous system, improve circulation, and increase general tone and endurance. The high temperatures in these baths expand the vasculature of the skin; stimulate metabolism, respiration, and circulation; and condition the thermoregulation system. Metabolic products are eliminated from the 12 V 4 Ch 7 Postflight Rehbilitation of Space Crews Bogomolov and Vasilyeva body though copious sweating. The frequency of sauna baths must not exceed twice a week, and the maximum temperature is 100°C for 10–15% humidity. Typically, the first sauna lasts only 5 minutes, with exposure time increase gradually to a maximum of 20 minutes. After the sauna, the cosmonauts rest in a supine or seated position for 30 to 45 minutes. Massage therapy in the sauna increases the efficacy of the massage and has positive effects on the emotional state. Finally, psychosocial measures also play important roles during this phase of rehabilitation. The social components are defined broadly, and include cosmonauts recognition of their new social status and relationship with others. In addition, time is devoted to leisure and cultural recreation, such as excursions to museums, exhibits, concerts, and theaters. Conclusions Our experience suggests that postflight rehabilitation has done much to enhance the professional longevity of cosmonauts and protect their ability to perform repeated space flights. However, several problems still remain to be resolved; for example, measures are still needed for rehabilitating older cosmonauts who develop health problems during flight. Moreover, plans for very long-term flights, such as those involved in interplanetary exploration, compel us to pay close attention to rehabilitation during flight, on the target planets, and after return to Earth. Six subjects were given no rehabilitative measures (Group 1, top), and 6 others (Group 2, bottom) were given a comprehensive rehabilitation program. White bars, before exercise; black bars, after exercise; dotted lines, at-rest baselines for that group before bed rest. The Phase I circle (left) reflects a typical restricted regimen (see text), in which passive measures constitute 75% of the program and active measures 25%. Progression through the restricted-training stage involves a 50%–50% mix of passive and active measures. The numbers at right indicate the distance swum and the number of days after landing. Mueller V4 Ch 8 Countermeasures to Short-Term and Long-Term Space Flight Grigoriev et al. The human body is exquisitely sensitive to changes in its surroundings and reacts to such changes with a high degree of precision. Modest changes to the gravitational force, for example, result as a sitting person stands or a sleeping person rises; these force differentials experienced by the cardiovascular system induce a host of regulatory mechanisms, which ensure that blood consistently reaches all extremities. More significant changes to the gravitational environment—such as the microgravity of space flight—challenge the bodys homeostasis to a much greater extent and initiate a host of complex adaptive mechanisms. In trying to predict how the human body might react to the novel space flight environment, flight physicians and researchers of the 1950s speculated that microgravity and space flight itself would present significant challenges to the human body. They hypothesized that the combination of acceleration during launch, weightlessness, and heavy deceleration during entry would be intolerable for a human being, causing serious disorders in organs and systems that relied on gravicentric cues. Given this grim forecast, every attempt was made to simulate the most challenging th aspects of human space flight and assemble a database of aviation experience. By the middle of the 20 century, researchers had employed high-speed aircraft, human centrifuges, water immersion, bed rest, and an assortment of other physiologic challenges. While these simulations proved that human space flight was indeed possible, they emphasized the importance of protecting and conditioning crews for the harsh new environment to which they would be subjected for the first time. Thus, the initial focus of human space flight was to demonstrate that humans could survive space flight and the subsequent return to Earth gravity. The central challenge for the Russian and American space programs was to ensure the safety and performance of crewmembers given the protection of life support and medical technology. An intrinsic focus of human space flight was identifying the specific physiologic changes—both transient and long term—that would need to be countered for a successful mission. Basic parameters, such as time course and severity, were measured to ascertain whether they constituted a normal reaction, an abnormal physiological state, or a serious impairment to function upon return to the 1-g environment. This chapter covers both American and Russian program experience with countermeasures to negative effects during short and long-duration flights. Origins of Space Medicine and Countermeasures the high-speed, high-altitude flights of the 1950s can be viewed as a natural precursor to human space flight. Research into full-pressure flying suits, centrifuge conditioning to high acceleration forces, and telemetry of medical data available for study and development became directly applicable to the challenges and concerns faced by the first space medicine researchers. While aviators had considerable experience flying at attitudes similar to those of space flight, astronauts and cosmonauts would be required to live and work for extended periods of time in this environment. Thus, space medicine developed as a branch of preventive medicine that focused on identifying and minimizing the hazards of space flight. Although its foundations were clearly rooted in aviation medicine, space medicine focused on a number of questions that the aviation medicine community had no need to address. Early missions demonstrated that multiple physiologic systems were affected both during and after flight, as had been predicted by extensive simulations and research. Consequently, the area of countermeasure development occupied a pivotal role in the early days of space medicine. The changes that astronauts and cosmonauts encountered upon return to Earth became the focus of specialists—physiologists, doctors, and engineers—since these alterations posed a significant threat to crewmembers and were more obvious than those observed during flight. However, as missions became increasingly complex and required more crew activity, researchers developed countermeasures to attenuate the most detrimental symptoms of the microgravity adaptation syndrome and maintain high crew performance at all stages of the mission. Despite individual and operational differences, all crewmembers returning from both short and long-duration orbital flights report two periods of adaptation. Both occur as the mission transitions from one gravitational environment to another: the first is experienced upon exposure to microgravity and the second upon return to Earth. The human body reacts to microgravity by exhibiting adaptations to a new stimulus. The symptoms of space motion sickness—cephalic fluid shift, atony, later atrophy of antigravity muscles, bone demineralization, and impaired metabolism of minerals—develop and become evident. Because space flight requires that crewmembers perform in and interact with a novel environment, the adaptations they experience are appropriate (albeit unpleasant); countermeasures to in-flight adaptations are designed to minimize crew discomfort and maximize crew safety. The return to Earths gravity requires a second period of readaptation, which again presents a significant challenge to crew activity and safety. Cosmonauts from long-duration Russian missions of eight months have required more than four weeks of rehabilitation to function normally. The most prominent in-flight and postflight adaptations include orthostatic intolerance, neurosensory dysfunction, and musculoskeletal decay. Orthostatic intolerance relates to the long-term functioning of the cardiovascular system during cephalic fluid shift that occurs in microgravity, which limits, upon return to Earth, the ability of many crewmembers to maintain long-term activity in a vertical position due to presyncopal or syncopal episodes. Neuromuscular and neurovestibular adaptations produce postflight disequilibrium (including marked vertigo in some cases) and gait disorders, which are conditions that clearly limit coordinated maneuvers and interfere not only with nominal egress but also with contingency egress. Significant and sustained loss of bone stiffness, documented at 10–20% during extended-duration missions, may cause injury, including bone fractures, especially during landing and postflight activity. Definitions and Parameters Countermeasures are operational tools, essential components of mission activities that permit crews to accomplish their duties with competence and ease. Although myriad complex and interrelated adaptations occur in response to microgravity exposure and the challenges of space flight, countermeasures target those physiological changes that threaten mission success or functioning upon return to the 1-g environment.

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