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These children can fall across the crib gym balloons or infated latex objects that are treated as balloons and not be able to inflammatory bowel disease video order voltarol 100mg without prescription remove themselves from that position (1) inflammatory bowel disease oral ulcers purchase cheapest voltarol. Aspiration injuries occur from latex bal loons or other latex objects treated as balloons inflammatory breast cancer 20 year old purchase voltarol cheap online, such as Soft objects/toys can cause suffocation anti inflammatory foods gout voltarol 100 mg for sale. The crib is not recommended as a place or gloves, these objects may break suddenly and blow an to entertain an infant or to “contain” an infant. Even though this is best practice for infants in any environ ment, the recommendation for prohibiting all crib gyms, Underinfated or uninfated balloons of all types could be mobiles, and all toys/objects in or attached to cribs may chewed or sucked and pieces potentially aspirated. The prevention of a potential brain injury Riding toys (such as tricycles) and wheeled equipment (such heavily outweighs a possible case of head lice. While it is as scooters) used in the child care setting should: best practice for each child to have his/her own helmet, a) Be spokeless; this may not be possible. If helmets need to be shared, it is b) Be capable of being steered; recommended to clean the helmet between users. Wiping c) Be of a size appropriate for the child; the lining with a damp cloth should remove any head lice, d) Have a low center of gravity; nits, or fungal spores. More vigorous washing of helmets, e) Be in good condition, work properly, and free of using detergents, cleaning chemicals, and sanitizers, is sharp edges or protrusions that may injure the not recommended because these chemicals may cause children; the physical structure of the impactabsorbing material to f) Be nonmotorized (excluding wheelchairs). However, because of their high center of grav Effectiveness of bicycle safety helmets in preventing head injuries: ity and speed, they often cause injuries in young children. Children should remove their helmets ftted and approved helmets while riding toys with wheels when they are no longer using a riding toy or wheeled (tricycles, bicycles, etc. Helmets should be re hazard if they are worn for other activities (such as playing moved as soon as children stop riding the wheeled toys or on playground equipment, climbing trees, etc. The standards sticker should be located Motorized wheeled equipment (excluding wheelchairs) used on the bike helmet. Bike helmets should be replaced if they by children in a child care setting does not promote good have been involved in a crash, the helmet is cracked, when physical activity (2). Vehicles used by children in child care straps are broken, the helmet can no longer be worn prop need to be child propelled rather than battery propelled. Helmet use is as departments for scooterrelated injuries were age eight or sociated with a reduction in the risk of any head injury by 69%, under (1). Infants are just learning to sit unsupported at permitting bicycling as an activity, the bike routes allowed about nine months of age. Until this age, infants have not should be reviewed and approved in writing by the local po developed suffcient bone mass and muscle tone to enable lice and taught to the children in the facility. Review and approval of bike routes be exacerbated by the added weight of a bicycle helmet on by the local police minimizes the potential danger (1). At least one adult who accompanies or drives children for the prevention of a potential brain injury heavily outweighs a feld trips and outoffacility activities should receive training possible case of head lice. While it is best practice for each by a professional knowledgeable about child development child to have his/her own helmet, this may not be possible. The If helmets need to be shared, it is recommended to clean caregiver should hold a valid pediatric frst aid certifcate, the helmet between users. Wiping the lining with a damp including rescue breathing and management of blocked air cloth should remove any head lice, nits, or fungal spores. Any emergency medications that a child might ing chemicals, and sanitizers, is not recommended because require, such as selfinjecting epinephrine for lifethreatening these chemicals may cause the physical structure of the allergy, should also be available at all times as well as a mo impactabsorbing material to deteriorate inside the helmet bile phone to call for medical assistance. Tip #7: Play it accordance with state and federal child restraint laws safe: Walking and biking safely. Should you take your baby (such as asthma, diabetes, or seizures), the driver or alongfi This standard plans, and should: also applies when caregivers/teachers are walking with 1) Recognize the signs of a medical emergency; children to and from a destination. This may include use of an attendance list of all reach of children; children being transported so it can be checked against 4) Know specifc medication administration (ex. Also, have another staff child who requires EpiPen or diazepam); member do a thorough and complete inspection of the 5) Know about water safety when feld trip is to a vehicle to see that the vehicle is empty before locking. Heat related deaths to young information (name, address, and telephone number) about children in parked cars: An analysis of 171 fatalities in the United the child care center. Guidelines for developing educational materials to address surroundings or routine changes. American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention, and Council on School Health. Policy Children have died from heat stress from being left unat statement: School transportation safety. Temperatures in hot motor vehicles can reach dangerous levels within ffteen minutes. Children left unattended also can should be at least twentyone years of age and should have: be victims of backovers (when an unseen child is run over a) A valid commercial driver’s license that authorizes the by being behind a vehicle that is backing up), power window driver to operate the vehicle being driven; strangulations, and other preventable injuries (1, 2). Training by someone with appropriate knowledge and impaired ability to drive, within twelve hours prior to experience is needed to appropriately address these issues. The child care staff should children, child neglect or abuse, substance abuse, or be knowledgeable about location and any emergency plans any crime of violence; of the location. Increased supervision and interactions between adults and children promotes safety and helps children learn to be the driver’s license number and date of expiration, vehicle aware of their surroundings. Plans for loading and unloading should be noncompliance with the restriction on the use of alcohol or discussed and demonstrated with the children, families, other drugs is suspected. Com a) A child should be transported only if the child pliance can be measured by testing blood or urine levels is restrained in developmentally appropriate car for drugs. Refusal to permit such testing should preclude safety seat, booster seat, seat belt, or harness continued employment. Is it safe pounds and under fourfeetnineinches tall and to drive a car when treated with anxiolyticsfi Evidence from on for all children considered too small, in accordance the road driving studies during normal traffc. Caregivers/teachers should not use a only at the curb or at an offstreet location protected from car safety seat if the child weighs more than the traffc. The facility should assure that any adult who super seat’s weight limit or is taller than the height limit. Manufacturer’s instructions that record of all children picked up and dropped off. The facility include these specifcations can also be found on the should assure that a staff member or adult parent/guard manufacturer’s Website. The adult who is supervising the child should be and used in accordance with the manufacturer’s required to stay with each child until the responsibility for instructions and should be secured in back seats that child has been accepted by the individual designated in only. The use of child safety seats reduces risk of death f) For maximum safety, infants and toddlers should ride by 71% for children less than one year of age and by 54% in a rearfacing orientation. In addition, booster seats the car) until they are two years of age or until they reduce the risk of injury in a crash by 45%, compared to the have reached the upper limits for weight or height for use of an adult seat belt alone (5). Headon crashes forward, the child passenger must ride in a forward cause the greatest number of serious injuries. A child sitting facing child safety seat (either a convertible seat or in the back seat is farthest away from the impact and less a combination seat) until reaching the upper height likely to be injured or killed. Additionally, new cars, trucks or weight limit of the seat, in accordance with the and vans have had air bags in the front seats for many manufacturer’s instructions (10). Air bags infate at speeds up to 200 mph and can limiting transportation times for young infants to injure small children who may be sitting too close to the minimize the time that infants are sedentary in one air bag or who are positioned incorrectly in the seat. If an infant is placed in a child safety seat facing for h) Car safety seats, whether provided by the child’s ward, a collision could snap the infant’s head forward, caus parents/guardians or the child care program, should ing neck and spinal cord injuries. If an infant is placed in a be labeled with the child passenger’s name and child safety seat facing the rear of the car, the force of a col emergency contact information. The rigidity of the bones in the neck, recalled, are past the manufacturer’s “date of use” in combination with the strength of connecting ligaments, expiration date, or have been involved in a crash that determines whether the spinal cord will remain intact in the meets the U. Based on physiologic measures, immature severity criteria or the manufacturer’s criteria for and incompletely ossifed bones will separate more easily replacement of seats after a crash (3, 11). After twelve restraint systems should be checked before use to months of age, more moderate consequences seem to prevent burns to child passengers. However, rear facing positioning that spreads deceleration forces over the If the child care program uses a vehicle that meets the largest possible area is an advantage at any age. Newborns defnition of a school bus and the school bus has safety seated in seat restraints or in car beds have been observed restraints, the following should apply: to have lower oxygen levels than when placed in cribs, as a) the school bus should accommodate the placement observed over a period of 120 minutes in each position (8).

Localized dilatations inflammatory bowel disease fellowship buy voltarol 100mg free shipping, the ampullae inflammatory breast cancer new treatments purchase 100mg voltarol mastercard, develop at one end of each semicircular duct pro-inflammatory foods arthritis cheap voltarol 100mg with visa. Specialized receptor areascristae ampullaresdifferentiate in the ampullae and in the utricle and saccule (maculae utriculi and sacculi) inflammatory bowel disease unmet need purchase voltarol now. From the ventral saccular part of the otic vesicle, a tubular diverticulumthe cochlear ductgrows and coils to form the membranous cochlea (see. The spiral organ (of Corti) differentiates from cells in the wall of the cochlear duct (see. Nerve processes extend from this ganglion to the spiral organ, where they terminate on the hair cells. Observe the otic vesicles, the primordia of the membranous labyrinths, which give rise to the internal ears. Note the ectodermal stalk, which is still attached to the remnant of the otic placode. The otic vesicle will soon lose its connection with the surface ectoderm (primordium of epidermis). A to E, Lateral views showing successive stages in the development of the otic vesicle into the membranous labyrinth from the fifth to eighth weeks. A to D, Diagrammatic sketches illustrating the development of a semicircular duct. F to I, Sections through the cochlear duct showing successive stages in the development of the spiral organ and the perilymphatic space from the 8th to the 20th weeks. Observe the relationship of these parts of the ear to the otic vesicle, the primordium of the internal ear. A, At 4 weeks, illustrating the relation of the otic vesicle to the pharyngeal apparatus. C, Later stage showing the tubotympanic recess (future tympanic cavity and mastoid antrum) beginning to envelop the ossicles. D, Final stage of ear development showing the relationship of the middle ear to the perilymphatic space and the external acoustic meatus. Note that the tympanic membrane develops from three germ layers: surface ectoderm, mesenchyme, and endoderm of the tubotympanic recess. Inductive influences from the otic vesicle stimulate the mesenchyme around the otic vesicle to condense and differentiate into a cartilaginous otic capsule (see. The transforming growth factor Ifi1 may play a role in modulating epithelialmesenchymal interaction in the internal ear and in directing the formation of the otic capsule. As the membranous labyrinth enlarges, vacuoles appear in the cartilaginous otic capsule and soon coalesce to form the perilymphatic space. The membranous labyrinth is now suspended in perilymph (fluid in perilymphatic space). The perilymphatic space related to the cochlear duct develops two divisions, the scala tympani and scala vestibuli (see. The cartilaginous otic capsule later ossifies to form the bony labyrinth of the internal ear. The internal ear reaches its adult size and shape by the middle of the fetal period (2022 weeks). The proximal part of the tubotympanic recess forms the pharyngotympanic tube (auditory tube). It has been suggested that, in addition to apoptosis in the middle ear, an epitheliumtype organizer located at the tip of the tubotympanic recess probably plays a role in the early development of the middle ear and tympanic membrane. The mastoid antrum is almost adult size at birth; however, no mastoid cells are present in newborn infants. By 2 years of age, the mastoid cells are well developed and produce conical projections of the temporal bones, the mastoid processes. Development of the External Ear page 433 page 434 the external acoustic meatus, the passage of the external ear leading to the tympanic membrane, develops from the dorsal part of the first pharyngeal groove. The ectodermal cells at the bottom of this funnelshaped tube proliferate to form a solid epithelial plate, the meatal plug (see. Late in the fetal period, the central cells of this plug degenerate, forming a cavity that becomes the internal part of the external acoustic meatus (see. The external acoustic meatus, relatively short at birth, attains its adult length in approximately the ninth year. The primordium of the tympanic membrane is the first pharyngeal membrane, which forms the external surface of the tympanic membrane. In the embryo, the pharyngeal membrane separates the first pharyngeal groove from the first pharyngeal pouch (see. As development proceeds, mesenchyme grows between the two parts of the pharyngeal membrane and differentiates into the collagenic fibers in the tympanic membrane. To summarize, the tympanic membrane develops from three sources: Ectoderm of the first pharyngeal groove Endoderm of the tubotympanic recess, a derivative of the first pharyngeal pouch Mesenchyme of the first and second pharyngeal arches the auricle (pinna), which projects from the side of the head, develops from mesenchymal proliferations in the first and second pharyngeal archesauricular hillockssurrounding the first pharyngeal groove. As the mandible develops, the auricles assume their normal position at the side of the head (see. Note that three auricular hillocks are located on the first pharyngeal arch and three on the second arch. As the mandible and teeth develop, the auricles move from the superior neck region to the side of the head. The parts of the auricle derived from the first pharyngeal arch are supplied by its nerve, the mandibular branch of the trigeminal nerve; the parts derived from the second arch are supplied by cutaneous branches of the cervical plexus, especially the lesser occipital and greater auricular nerves. The facial nerve of the second pharyngeal arch has few cutaneous branches; some of its fibers contribute to the sensory innervation of the skin in the mastoid region and probably in small areas on both aspects of the auricle. Congenital Deafness page 434 page 435 Because formation of the internal ear is independent of development of the middle and external ears, congenital impairment of hearing may be the result of maldevelopment of the soundconducting apparatus of the middle and external ears or of the neurosensory structures of the internal ear. Approximately three in every 1000 newborns have significant hearing loss, of which there are many subtypes. Most types of congenital deafness are caused by genetic factors, and many of the genes responsible have been identified. Congenital deafness may be associated with several other head and neck anomalies as a part of the first arch syndrome (see Chapter 9). Congenital fixation of the stapes results in conductive deafness in an otherwise normal ear. Failure of differentiation of the anular ligament, which attaches the base of the stapes to the oval window (fenestra vestibuli), results in fixation of the stapes to the bony labyrinth. This designation is made when the margin of the auricle or helix (arrow) meets the cranium at a level inferior to the horizontal plane through the corner of the eye. Almost any minor auricular defect may occasionally be found as a usual feature in a particular family. Minor anomalies of the auricles may serve as indicators of a specific pattern of congenital anomalies. For example, the auricles are often abnormal in shape and lowset in infants with chromosomal syndromes. Auricular Appendages Auricular appendages (skin tags) are common and may result from the development of accessory auricular hillocks. The appendages usually appear anterior to the auricle, more often unilaterally than bilaterally. The appendages, often with narrow pedicles, consist of skin but may contain some cartilage. Absence of the Auricle Anotia (absence of the auricle) is rare but is commonly associated with the first pharyngeal arch syndrome (see Chapter 9). Microtia Microtia (a small or rudimentary auricle) results from suppressed mesenchymal proliferation. This anomaly often serves as an indicator of associated anomalies, such as an atresia of the external acoustic meatus and middle ear anomalies. Preauricular Sinuses and Fistulas Pitlike cutaneous depressions or shallow sinuses are occasionally located in a triangular area anterior to the auricle. Preauricular sinuses may be associated with internal anomalies, such as deafness and kidney malformations.

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Birth Rituals or fi Daily private prayer and annual fast lasting throughout day from Ceremonies sunrise to is xylitol inflammatory cheap voltarol 100mg online sunset March 220 inflammatory breast cancer video clip discount voltarol 100mg amex. Beliefs fi Fundamental interconnectedness of all natural things; all forms of life inflammatory root resorption order cheap voltarol line, with the land are of primary importance inflammatory rheumatoid arthritis order generic voltarol pills. Facilitating fi Provide time, space, privacy & include the spiritual leader or elder. Practices fi Do not pretend to be familiar with traditions and do not interfere with them. Health fi May believe that all bad health results from not living in harmony or being out of balance with nature, social relationships, and/or supernatural environments. Holy Days & fi Closely related to seasonal changes, the moon, provision of food Festivals and other life essentials. Birth fi Avoid wearing Lei or garlands in a full circle are practiced to avoid unfortunate circumstances. Rituals & fi Performed with intent of seeing, understanding, or obtaining a Ceremony vision of clarity of oneself and individual issues in order to relate to one‘s self and others. Spiritual fi There are no written scriptures or writings; everything is handed instruments, down by generations, practices, traditions, & stories. Daily Practices fi Prayers, may include using sacred objects, usually private and without strangers present. Food fi After ceremony or prayer, foods consumed will likely be provided by family. Holy Days and fi Closely related to seasonal changes, the moon, provision of food Festivals and other life essentials. Birth Rituals or fi Performed with intent of seeing, understanding, or obtaining a Ceremonies vision of clarity of oneself and individual issues in order to relate to oneself and others. Spiritual fi No written scriptures; ceremonies and beliefs learned by word of Instruments, social mouth and instruments experience. Rastafarian Movement *Started in the 1930‘s in Jamaica *About 10% of Jamaicans are Rastafarian Beliefs fi One God, Jah, is the former emperor of Ethiopia (Haile Selaissie I) incarnated. Daily Practices fi Often wear dreadlocks, either as a religious decision or a style decision. As a result, they might be hesitant to Death prepare for death or talk about terminal illness. Therefore it is sacred and they may be hesitant to put anything unnatural into it. Healing fi May seek a Santeria priest for physical and mental healing who may use herbal formulas, prayers, and ritual. Voodoo *There are many variations of Voodoothe following describes Voodoo Spirituality found in the United States Beliefs fi There is one God, Bondye, and many other spiritual beings, called Iwa. Practices fi Consecrated items must not be removed from patient or handled by anyone but the wearer. Festivals Pregnancy and fi Rituals for blessings of pregnancy performed by women of Birth community and are held every trimester of pregnancy. Ceremonies fi Full moon held to be a time of great magical energy, a good time for putting a lot of effort into one‘s spiritual life and work. Instruments, fi Consecrated pendant in the form of a pentacle/pentagram social structure (interlaced five pointed star within a circle) is often worn; don‘t and symbols remove without asking. Issues fi Extremely diverse population; determine subgroup, such as Caribbean or African immigrants/cultures. Clothing or Amulets fi Religious items Language fi English Communication, fi May have regional dialects. Nonverbal, and fi Refusal to sign forms could indicate literacy issues or distrust. Health, Illness and Death Illness beliefs fi Varies from natural causes and exposure to cold air to God‘s punishment or work of devil or a spell/curse. Invasive Procedures fi Historically skeptical, though with clear explanations, needed surgery is accepted. DeathSpecial fi May have spiritual practices or rituals that can vary from Islam to Needs Baptist Christianity. Organ Donation fi May be hesitant due to lack of trust, faith issues, or fears; however number of consents continues to increase. Pregnancy, Birth, Postpartum Prenatal Care fi Varies; may wait until after first trimester. Breastfeeding fi Breastfeeding benefits need to be explained Genetic Defects fi May be viewed as God‘s will. Religious and Spiritual Practices Religion fi Prayer, visits from spiritual leader and/or faith group members depending upon spiritual tradition. HispanicAmerican Culture Preferred Term: Hispanic or Latino Cultural and Family Structure Important Historical fi Wide diversity due to area of historical or recent country of Issues origin Clothing or Amulets fi Religious items, such as rosaries, frequently kept on person or on bed. Communication, fi Differences in word usage depending on individual‘s home and Nonverbal, and region. Family structure fi Strong sense of loyalty, reciprocity, and solidarity among members. Health, Illness and Death Illness beliefs fi Health is controlled by God and by fate. Terminal Illness fi Family may want to protect patient from knowledge of Discussion seriousness of illness due to concern that worry will worsen health status. Pregnancy, Birth, Postpartum Prenatal Care fi May believe unnecessary; assess for barriers such as finances, © HealthCare Chaplaincy Network 2014 Page 36 transportation fi May use folk medicine and have traditional beliefs, such as mother avoiding evil eye, be frightened, or having cravings unfulfilled; beliefs not always shared with practitioners. CSection fi If needed for health of mother or baby Postpartum and fi May resist getting out of bed for or taking showers for several Breastfeeding days. Native American Culture Preferred Term: Tribal Name Cultural and Family Structure Important Historical fi Native American culture is not comprised of only one Issues tribe/nation but rather a collection of many. Greetings fi Tone expresses urgency; when imperative command required, be direct, emphatic, clear, and calm. Spokesperson and fi Generally, individuals speak for themselves, family members may Decisionmaking speak on behalf of person who is ill. Food fi Hospitality and respect may lead patient to sharing hospital food practices/beliefs with visiting family and friends as well as consume food brought by visitors. Time orientation fi Emphasis on present moment may conflict with appointment schedules. Health, Illness and Death Illness beliefs fi Mental illness a culturally specific concept; beliefs about cause may include ghosts, breaking taboos, or loss of harmony w/environment. Invasive Procedures fi May be skeptical of procedures but will allow treatment if needed. DeathSpecial fi Be prepared to support or inquire if family wants to bring in tribal Needs healers to attend to spiritual health. DeathBody Care fi Traditional practices include turning and/or flexing body, sweetgrass smoke care or other purification, women may want to prepare and dress body. CSection fi Acceptable if needed for health of mother or baby Postpartum and fi Viewed as important for mother and baby to rest Breastfeeding fi Umbilical cord has spiritual meaning; typically saved by family for ritual fi Breastfeeding and bottle both acceptable. Religious and Spiritual Practices Religion fi Do not expect traditional religion to be openly discussed. Native Hawaiian – American Culture (Content provided by: Kanoelani Davis, Cultural Health Navigator Manager, Molokai Community Health Center) Preferred term: Hawaiian Culture & Family Structure Demographics fi 1. Symbols fi Clothing & Amulets: Cloth wrapped on one shoulder called kihei, used for protection and/or status fi the way it‘s tied can signify authority, male/female, or significant moment in life fi Salt called pa‘akai is used for purification and ti leaf lei or garlands for protection Language fi Hawaiian: fiOlelo Makuahine fi Pidgin/creole English fi AmericaEnglish Communication fi Do not interrupt speaker. Food practices/ fi Eating is important for recovery; offering food is associated with beliefs nurturing fi Beliefs caring for, accepting, and trusting. Nonverbal fi Listening is key, body language, strongly influenced by respect, cautious in disclosure of thoughts to nonintimates, aware of external judgment and concerned with respectability and good appearance. They are the main caretakers although they will usually consult with the male family member to come up with a mutual decision. Time orientation fi On time kept for official business and more spontaneous for social and informal gatherings; emphasize importance of appointment times. The female will take the role in filling and prepping all paperwork, please allow time for family to come up with a decision. Dying process fi Attendance from family and relatives expected but independence maintained. Invasive procedures fi May be skeptical of procedures but will allow treatment if needed.

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Report on the Ebola crisis: the longterm lessons and how to inflammatory breast cancer how common purchase cheap voltarol on-line strengthen health systems in developing countries to inflammatory writing buy discount voltarol 100 mg line prevent future crises inflammatory knee order 100mg voltarol with amex. Do Men Have a Higher Case Fatality Rate of Severe Acute Respiratory Syndrome than Women Dofi inflammatory bowel disease stress generic voltarol 100mg with visa. Ebola Impact Revealed: An Assessment of the Differing Impact of the Outbreak on Women and Men in Liberia. A casecontrolled study comparing clinical course and outcomes of pregnant and nonpregnant women with severe acute respiratory syndrome. Prevalence and patterns of tobacco smoking among Chinese adult men and women: findings of the 2010 national smoking survey. Munoz Boudet, Ana Maria, Paola Buitrago, Benedicte Leroy de la Briere, David Newhouse, Eliana Rubiano Matulevich, Kinnon Scott, and Pablo SuarezBecerra. Gender Differences in Poverty and Household Composition through the Lifecycle: A Global Perspective. The Perspective of Gender on the Ebola Virus Using a Risk Management and Population Health Framework: A Scoping Review. GenderBased Violence Among Adolescent Girls and Young Women: A Neglected Consequence of the West African Ebola Outbreak. Global Maternal and Child Health book series, Springer: Cham, Switzerland: 12132. Perceptions and Behaviors Related to Hand Hygiene for the Prevention of H1N1 Influenza Transmission among Korean University Students During the Peak Pandemic Period. The Psychosocial Aspects of a Deadly Epidemic: What Ebola Has Taught Us About Holistic Healing. Assessing Sexual and Gender Based Violence during the Ebola Crisis in Sierra Leone. SocioEconomic Impact of Ebola Virus Disease in West African Countries: A Call for National and Regional Containment, Recovery and Prevention. Genderrelated inequalities emerging from Covid19: Preliminary thoughts on impacts and recommendations: Focus on Transport sector (Internal document). The evidence from the Ebola epidemic, despite focusing on Western Africa, offers special insights since lock down and school closures were also adopted during the containment phase in the worst hit countries. See Minor (2017) and Carter, Dietrich and Minor (2017) for a detailed discussion drawing on the experience of the 20136 Ebola epidemic in West Africa. Examinees should refer to the test specifications for each examination for more information about which parts of the outline will be emphasized in the examination for which they are preparing. Although the surgical care for these conditions is costeffective, many people do not have access to hernia repair and hydrocelectomy. These essential operations must be prioritized and integrated into primary healthcare delivery systems in low and middleincome countries. We present our estimation of the global and regional burden of disease from groin hernia, the first of its kind in the literature. In addition, we highlight the existing data on the costeffectiveness of surgical treatment for groin hernia and hydrocele. Groin hernia repair and hydrocelectomy are costeffective curative therapies that can improve quality of life. In addition, herniorrhaphy can prevent lifethreatening complications associated with groin hernia. The treatment of groin hernia and hydrocele should be a high priority on any global surgery agenda. Basic surgical care for these conditions is a crucial part of primary health care services that should be available at districtlevel hospitals. A groin hernia is a specific type of hernia involving the bulging of abdominal contents through the inguinal or femoral canal. The inguinal canal is a “corridor” in the abdominal wall, which houses the spermatic cord as it passes on its way to the testicle in men. Inguinal hernias may be caused either by a failure in the normal closure of the abdominal lining in the inguinal canal during fetal development, or by an acquired weakening of the abdominal wall. In either case, the hernia sac, which may contain fat, ovary, bowel, or bladder, protrudes through the abdominal wall into the inguinal canal. A scrotal hernia is a type of inguinal hernia in which the hernia sac, often containing bowel, follows the path of the spermatic cord into the scrotum. Femoral hernias occur rarely and involve the protrusion of abdominal contents through the femoral canal, a space adjacent to the femoral vein in the upper thigh. Groin hernias may be further classified as reducible, incarcerated, or strangulated. Scrotal and femoral hernias are more likely to become incarcerated and cause complications. Black race and obesity were associated with a lower incidence of inguinal hernia in the cohort (Ruhl and Everhart 2007). It is likely that different types of physical activity are associated with different levels of risk, and further study is needed on this topic. Other risk factors for groin hernia include a family history of hernia and the presence of a hiatal hernia (Ruhl and Everhart 2007). Populationbased studies are nearly impossible today since inguinal hernia repair is at least somewhat available in most settings. The little contemporary data that exist are limited by selection bias (Gallegos and others 1991). The key question in determining the natural history of hernia centers on the identification of the annual risk of hernia accident (that is, bowel obstruction, incarceration, or strangulation) without hernia repair. To address this question, Neuhauser examined data in two settings where herniorrhaphy was generally not practiced: Paul Berger’s Paris truss clinic (circa 1880) and Cali, Colombia (circa 1970). These calculations suggest that hernia accident is a relatively common lifetime event in younger patients with unrepaired inguinal hernia. In a prospective study from Ghana, 67 percent of patients presenting for repair had scrotal hernias, placing them at increased risk of hernia complications. When the Ghanaian cohort was compared to a similar group of patients from the United Kingdom, the Ghanaians were found to be younger and have larger hernias (Sanders and others 2008). In Tanzania, nearly half of hernia patients in one study presented for repair more than five years after disease onset (Mabula and Chalya 2012). For example, in another Ghanaian hernia cohort, 16 percent of hernia patients were unable to work, and 64 percent reported limited daily activity (Sanders and others 2008). In a prospective study of 6, 895 patients in the Swedish Hernia Register, only 5 percent of groin herniorrhaphies in men were classified as emergencies (Koch and others 2005). Over twothirds of inguinal hernias repairs at a tertiary referral center in Kumasi, Ghana, were emergency operations (OheneYeboah and others 2009). In a recent study from Bugando Medical Center in Tanzania, more than half of presenting groin hernias were incarcerated, while 18. An estimated 20 million groin hernias are repaired annually worldwide (BayNielsen and others 2001). A study from the United Kingdom found a 27 percent lifetime risk for inguinal hernia repair in men and 3 percent in women (Primatesta and Goldacre 1996). A rigorous communitybased survey demonstrated an inguinal hernia prevalence of 18. Not surprisingly, the incidence of inguinal hernia repair is lower than disease incidence. A recent retrospective review of all inguinal hernia repairs in Minnesota over a 20year period found an incidence of hernia repair of 217 per 100, 000 personyears (Zendejas and others 2013). This means that approximately 670, 000 inguinal hernia repairs are performed annually in the United States. The annual inguinal hernia repair rate in the United Kingdom (130 per 100, 000 population) is lower than the rate of repair in the United States (Primatesta and Goldacre 1996). The authors attributed the lower incidence of inguinal hernia in Tanzania to the relative youth of the population compared to that of the United States. Despite demonstrating a lower incidence of inguinal hernia, Beard and colleagues estimated a relatively high prevalence of inguinal hernia in Tanzanian men at 12. Because heavy labor and racial factors have not been clearly substantiated as significant inguinal hernia risk factors in the literature, the authors attribute the higher prevalence of hernia in SubSaharan Africa to a lack of access to surgery in the region (Lau and others 2007; Ruhl and Everhart 2007).