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Reliability of commonly used predictors of diffcult intubation experienced anesthesiologists and 50 (38-69) sec in the resident (p=0 impotence young buy cheap kamagra super on line. Thanks to erectile dysfunction 26 buy kamagra super cheap new technology trimix erectile dysfunction treatment buy kamagra super once a day, wide become even worse for patients who are anticipated to varicocele causes erectile dysfunction purchase kamagra super 160 mg overnight delivery have a diffcult airway. The primary outcome of this survey was to determine the types of mask ventilation diffculty during anesthetic induction. The secondary aim was to determine Materials and Methods: 88 patients who were predicted for diffcult mask ventilation the preferred characteristics of videolaryngoscopes. After anesthetic induction using Materials and Methods: Following Ethics Committee approval, a multiple-choice propofol (2mg/kg) and rocuronium (0. Answers were also held with one hand and ventilation was performed using a reservoir bag in the circle system. Real time sonography on the gastric antrum was performed to detect gas insuffation during mask ventilation. Gastric insuffation was hyperangulated blades, 44% of them were using Macintosh-like blades. However, the benefts of this approach have never (United States) been scientifcally validated. We thus compared the early and late administration of rocuronium before and after checking mask ventilation to investigate the effciency of mask ventilation and the time to tracheal intubation in patients with normal Background and Goal of Study: A clinical study has demonstrated that recurrence airways. The aim of this study was to determine the effect of magnesium at 10, 20, 30, 40, 50, and 60 s after apnea during mask ventilation. Patients were Results and Discussion: the average of mask tidal volumes measured at 10, randomly distributed electronically into two groups, according to the solution infused: 100 mL solution containing 60 mg. The differences in tidal volumes between the groups were signifcant at 10, was maintained with remifentanyl infusion and target controlled infusion of propofol. The time from apnea to tracheal intubation was shorter in the early rocuronium group than in the sugammadex bolus. References: Magnesium acts at the neuromuscular junction and potentiates minimal amounts 1. However, there are few 2 3 reports about postoperative sore throat in nasotracheal intubation. In this study, we Universidade Federal Fluminense Niterói (Brazil), Americas Medical City Rio de Janeiro (Brazil), 4Hospital Federal de Bonsucesso Rio de investigated the risk factors of postoperative sore throat in nasotracheal intubation, retrospectively. Janeiro (Brazil), 5Universidade Federal Fluminense Niterói (Brazil) Materials and Method: Anesthesia records of the patients (16-80 yrs) with nasotracheal intubation were checked. Patients underwent oral maxillofacial Background and Goal of Study: A clinical study has demonstrated that recurrence surgery from February 2015 until September 2018. Patients were of postoperative sore throat; Sore throat group and Non-sore throat group, randomly distributed electronically into two groups, according to the solution respectively. The occurrence of postoperative sore throat was correlated with airway infused: 100 mL solution containing 60 mg. After anesthetic induction and loss of (n=45) or fberscope (n=34) vs Non-sore throat group: Mackintosh laryngoscope consciousness, contraction of the adductor pollicis muscle in response to ulnar (n=14), video laryngoscope (n=36) or fberscope (n=4) (p<0. Fiberscope had the strongest infuence on the incidence of sore throat of propofol. The study solution was administered after-1 the fberscope might give damage around the vocal code, as it is a blind procedure. Categorical data were compared using Fisher’s A short training session in both techniques was provided prior to the study start. Primary outcome was the time necessary until position of either tracheal tube or pen Results and Discussion: We analyzed 29 cases. Readministration of sugammadex was required and self-evaluated competence level before and after training. Results and Discussion: 30 participants, aged 36±9 years, 37% female Magnesium acts at the neuromuscular junction and potentiates minimal amounts participated. It has a different design to other intubation assists, as it has an open channel, a longer tail, and is metal. Each participant then performed 10 oral fbreoptic intubations on a manikin, 5 with the Bartlet airway and 5 without. Time 1Laiko General Hospital of Athens, University of Athens, Greece to carina and to ventilation were recorded. Athens (Greece) Results and Discussion: There was a signifcant reduction in median time to carina and time to ventilation between the 1st and 10th intubation (Table 1). Table 1: Time to carina and ventilation for all intubations Background and Goal of Study: Aspiration of gastric contents is a major cause of anesthesia-related morbidity and mortality. Approximately 10% of respiratory1 1st intubation 10th intubation p = complications leading to death or permanent brain damage are related to aspiration. Moreover, techniques to prevent aspiration have become a focus of2 Median time to carina (secs) 68 17 0. However, there was a greater decrease in time to ventilation with the Bartlet were collected. Data are presented as absolute numbers, percentages and mean airway (102 seconds to 38 seconds vs 88 seconds to 36 seconds, p value =0. This difference however was not statistically (10%) patients died during the same admission. Conclusions: There was no statistically signifcant difference in time to visualisation Nine (22. The improved timing of intubations from the 1st to 10th intubation indicates Gastroesophageal refux disease was documented in 25 (62. Locations the success of repetitive practice in the skill acquisition of fbreoptic intubation for outside of the operating room accounted for 23 (57. Efforts should be made to identify predictors of aspiration with the goal of developing practice improvement strategies for our institution. Aguilera 1ⅠJ Trauma 2004;56:1221-28 1Hospital Del Mar Barcelona (Spain), Departments of Anesthesia, 2ⅠCardiovascular Anesthesia 2015;19: 49-54 3ⅠAnesth Analg 2015;121:868-78 Nephrology* and Urology**, Parc de Salut Mar. Decrease of platelet aggregation and inhibition of thrombus formation, increases the risk of bleeding, anemia, blood transfusion and postoperative complications1. Materials and Methods: We used a large cohort to assess the effect of Packed red blood cells(n) 1. Further studies are need2 Results: A total of 1,469 patients were analyzed with the median follow-up to confrm our fndings interval of 44. The weighted Cox regression models showed patients with transfusions of red blood cells have higher risks of cancer recurrence (1-4 units. Conclusion: A signifcant dose-response relationship was observed between the function? Background and Goal of Study: It is often diffcult to stop bleeding during the procedure of aortic arch replacement. However, we will face Universität Essen (Germany), Complejo Hospitalario Universitario de la Coruña La Coruña (Spain), 5Complejo Hospitalario Universitario the diffcult situation within 10 years. Japan’s aging society and its declining birth rate are threatening to upset the balance of supply and demand of blood products. The objective of this study was to review the effectiveness of changing the maximum number of platelets collected. The incidence of each category above was in outcome between tranexamic acid or not, which adjusts the size of difference compared using the independence test (by the chi-squared or Fisher’s exacts test). Past study shows up to 600ml of plasmapheresis can be collected safely at the adjusted p value of 0. And as the number of platelet would recover within a pooled data had insuffcient power. We expect this increase will make the risks of having fewer donors in the future reduced. This caterpillar is also called the fre insect because of the hair that cover all the body is full of a toxic venom. The venom causes disseminated intravascular coagulation and a consumptive coagulopathy, which can lead to a hemorrhagic syndrome. It contains toxins with procoagulant, anticoagulant and antithrombotic activities, affecting also the endothelium. Case report: A 45-years-old male entered the emergency room with extreme pain and edema in the ankle and left calf. He had no history of trauma, was previously healthy, and his symptoms started slowly two days ago. The patient had no foot pulse and the orthopedist made the compartment syndrome diagnosis and brought the patient to the operation room for a fasciotomy.

When necessary erectile dysfunction gene therapy treatment order 160mg kamagra super with amex, use of remedial and rehabilitation measures during rescue erectile dysfunction treatment germany best buy kamagra super, en route erectile dysfunction patient.co.uk doctor discount kamagra super 160 mg on line, at the Cosmonaut Training Center erectile dysfunction vyvanse discount kamagra super 160 mg visa, and at the rehabilitation sites. Hygienic/disinfection measures in evacuation vehicles and at sites visited by the crew. Assessment of the efficacy of onboard countermeasures in order to improve them further. Development of recommendations directed toward optimizing the restoration of the professional performance capacity of crewmembers after space flights. Prediction of whether a crewmember will be able to participate in further space flights. Development of recommendations to support effective training of crews for future space flights. The ultimate objective of medical monitoring is determining the nature, scope, and schedules of remedial health measures during the various periods of readaptation. The measures used during the acute period of readaptation are directed at restoring health and treating problems, They include a light regimen of motor activity, prevention of orthostatic disorders. The measures used during the subsequent (subacute) period of readaptation include a light schedule of motor activity with gradual increase to a training schedule, a balanced diet with four meals per day, light morning gymnastics, controlled-pace walking, physical therapy, general and relaxing massages (daily), baths in water saturated with carbon dioxide, pool swimming /aquatic gymnastics, electrical stimulation of the leg muscles, drug therapy (as indicated), and psychological stress reduction. The nature and schedule of remedial health measures used, and the points at which are utilized during evacuation and rehabilitation are prescribed on the basis of a crewmember’s health status. Timelines for use of various measures are established on the basis of results of medical monitoring and are determined by the severity of the adverse changes induced by space flight factors, the state of health and performance capacity of a crewmember, the efficacy of in-flight prophylactic measures against deconditioning, and the conditions and efficacy of the readaptation measures used. The extent to which health and the functional and physical status of crewmembers is restored after use of rehabilitation measures is assessed from the results of a final clinical physiological examination, which is used to derive or adjust individualized plans for subsequent biomedical support. Six months after completion of a space flight, cosmonauts undergo an inpatient medical examination to determine fitness for the next cycle of special training. The purposes of this program are to identify space flight medical risks and their influence on crew health and mission success, to identify medical capabilities that are essential in providing optimal health care during space flight, and to identify the long-term consequences of space travel under specific conditions so that preventive measures can be investigated and instituted. This multifaceted risk management includes elements such as collection and consolidation of medical data from astronauts, cosmonauts, and analogous populations; surveys of informed medical opinion, and comparison of risk management methods used in other organizations. Subcomponents of this program include ground-based longitudinal studies of astronaut health. An epidemiological cohort study is underway to examine the incidence of acute and chronic morbidity and mortality in astronauts and in several control groups over time. A similar but more focused in-flight study to be conducted in parallel will track and analyze the incidence of illness and injury during space flight. Until sufficient medical data from space flight are collected to reach statistical confidence limits, data from various analog populations will continue to be evaluated for comparison and application to space-medicine models. A more profound understanding of the medical risks associated with space flight confers several long-term benefits, among them the ability to apply that understanding to the allocation of program resources and mission planning, to the refinement of medical selection standards, and to the prioritization of biomedical investigations and development of preventive countermeasures. Automated Medical Monitoring and Database Development in the Russian space program Advances in space medicine and associated progress in human performance in space have reached a level that seemed ambitious 30 years ago. However, further progress is difficult to achieve if radical changes are not made in † Transliteration from Russian “sanatorium”; health resort with enhanced and recreation facilities and personnel. The Russian space program uses several facilities of the Ministry of Health; particular resort is selected on an individual basis depending on the specifics of the rehabilitation tasks, time of the year and crew preferences. The amounts of data previously obtained and the rate at which new data are being accumulated (including projections for the future) are so great that it is already difficult to handle them comprehensively. Furthermore, most data are received currently in forms that are unsuitable for integrated processing, complete analysis, and support of scientific conclusions. In many cases, physiological and other data from various phases of training for crewed flights, during the flight itself, and during the postflight period, are obtained by different specialists in different locations. While generally true in the international setting, this situation is not uncommon even within particular space programs. In such conditions, same clinical or physiological parameters may be presented in different formats and units and may even have differing significance, and normal values due to different equipment and/or methods used to obtain them. When the data obtained by various organizations (services) is initially incompatible. The increase in demands made on hardware for collecting data and on results of information processing for immediate reliable assessment of physiological status to enable prediction of future state, especially on long-term flights, makes it important to perform integrated processing of physiological and medical data. These requirements compel development of techniques for more efficient extraction of information from dynamic parameters and for integrated processing of data taken at different times. An effective solution to these problems is the application of certain information processing methodologies and the development of concepts for a centralized computer database 36 containing various parameters and descriptions relating to space flights. The role and place of a database in a system of medical monitoring and medical support of space flights will be determined by the importance and nature of the decisions made at various stages in the work of the medical service. Russia has had experience in developing databases applicable to the phases of training and direct medical support of space flights. The creation of a database on the results of training for and completion of long-term space flights onboard Russian space stations and future space stations is of particular importance. Some specialists believe that such a database will also allow to confirm early indications that a cosmonaut is failing to adapt or is under excessive stress and also of pathological deviations and diseases. To find a solution for any of these problems, medical personnel turn to medical research data. In on-line medical monitoring, there must be compact (concise) representation of changes over time in a large number of parameters and any instance where one of them exceeds the normal limits must be indicated. Prediction will require a great amount of retrospective information which is processed and analyzed using appropriate algorithms from various prognostic models. For diagnosis, along with data obtained in flight, additional specific data is needed on each cosmonaut, such as his or her medical history, results of laboratory and other studies, and data on status and reactions during selection and training. Thus the database in the system of medical monitoring must support the solution of various problems and at the same time meet scientific needs. The two major scientific objectives are to establish new scientific facts and identify new scientific principles for obtaining new knowledge in the area of space medicine; and to improve the medical monitoring and medical support of space flight systems, using near-real-time analysis of information. The files will consist of records, each of which in its turn consists of information from a certain event (for example, the set of measurements of several parameters at a certain moment of time). The records are “time-linked” as well as associated with a particular cosmonaut, and to the specific conditions under which the data were obtained. The records consist of fields containing individual information elements (such as dates, times, parameter values, textual information, and service codes). Different files contain information related to different sets of measured parameters, such as the schedule of events on board, the personal data for each cosmonaut, and the conditions under which medical studies were performed (tests, loadings etc. Thus, it becomes possible to automate retrieval of specific information through programmable queries (period, cosmonaut, type of study, loading, etc. Aside from solving the problems listed above, a centralized database makes it possible to ensure a more detailed and thorough statistical analysis of the medical information obtained not only to enable on-line decisions, but also to identify patterns of physiological reactions to space flight conditions. In addition, this database can be used to support the derivation, implementation, and testing of mathematical models of physiological systems affected by space flight. Russian Biomedical Training Information System the information environment describing the results of biomedical training of cosmonauts for space flight contains approximately 6000 quantitative and qualitative variables, evaluations, conclusions, and curves obtained from approximately 100 types of medical studies, exposures to various factors, and training procedures. The information system is a means for providing automated information support of biomedical training. The main goal of information support of biomedical training is the timely provision of reliable information on all aspects of the state of health and psychophysiological readiness of a cosmonaut to perform the biomedical aspect of the program in an upcoming flight. The biomedical training information system developed by the Institute of Mathematics of the Byelorussian Academy of Sciences uses the “Entry” database management system implemented on a minicomputer. The core of the system is the data stored on the minicomputer, and these data form the information environment describing various aspects of biomedical training. Information on the results of biomedical training is distributed among 13 fully independent bases, the information in which covers all aspects of biomedical training. The structure, scope, and contents of the primary information stored has been formalized. Primary information from keyboards and magnetic media can be keyed in the input format;. Information can be presented in the format in which it is stored in the computer or in formats stipulated by the user; and.

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Superior cervical ganglion n enter Superior cervical the skull with the carotid plexus n cavernous ganglion plexus n travel over the Gasserian ganglion along first division of the trigeminal nerve Middle cervical Ciliospinal n nasociliary nerve n long ciliary nerves kidney disease erectile dysfunction treatment purchase kamagra super 160 mg on-line, ganglion centre entering the globe with the long ciliary arteries (some perhaps running without a relay along Annulus of the long and/or sympathetic root of ciliary Vieussens ganglion n short ciliary nerves) impotence divorce purchase kamagra super 160 mg online, traversing the epichoroidal space to erectile dysfunction qatar 160 mg kamagra super with amex reach the iris and Inferior cervical terminate in the dilator muscle erectile dysfunction gabapentin cheap 160 mg kamagra super with amex. They run over the anterior part of the Gasserian ganglion and the pupils participate in several refexes, three of which are pass into the frst or ophthalmic division of the ffth nerve, of clinical importance: following the nasal branch, which they fnally leave to enter the long ciliary nerves, thus avoiding the ciliary ganglion. Like shared equally by the pupil of the other eye (the consen them, the long ciliary nerves run forward between the sual light reflex). Such cases do occur, but every pathological cause the Light Refex must be eliminated before concluding that the condition the light refex is initiated from the rods and cones is an idiosyncrasy. The fbres run up the optic nerve, pupils varies widely in different people under the same partially decussate in the chiasma and enter the optic conditions of illumination. The pupils are smaller in older tracts with exactly the same distribution as the visual fbres people than in the young, sometimes to so great an extent (Fig. Near the upper end of the tract, however, they that the pupils are almost ‘pin-point’. They are often part company with the visual fbres and, instead of running smaller in hypermetropes and larger in myopes than in to the lateral geniculate body, they enter the pre-tectal re emmetropes, and are commonly smaller in blue eyes than gion. It is obvious light reflex from a study of these paths that a lesion distal to the chi asma will abolish the direct reaction in the eye on the Ciliary affected side and the consensual reaction on the other ganglion (Fig. In its sudden response, the V pupil as it were oversteps the mark, oversteps it again in the Lateral geniculate Pre-tectal nucleus opposite direction, and so on. The numbers denote lesions accompanied by the following symptoms: large and easily seen, and are to a great extent independent of the light falling upon the eye. This is called hippus; it (I) Optic nerve: unilateral amaurotic paralysis (abolition of the direct depends upon the rhythmic activity of the nervous centres, reaction on the ipsilateral side and the consensual on the contralat eral side: retention of the consensual on the ipsilateral side and the and is not a peripheral phenomenon. From these muscles, afferent fbres reaction with retention of consensual reaction; retention of both contralaterally. At the same time, accommodation reinforces the refex by visual impulses relayed from the cortex to the Edinger– mid-brain, travel to the Edinger–Westphal nucleus on each Westphal nucleus. From these nuclei, the constrictor fbres travel to each iris as already described. The afferent pathway for the convergence Psycho-optical Convergence reflex reflex is indicated as running up the near reflex third nerve: this is not certain. That for the accommodation reflex follows the visual fibres to the striate area of the cal carine cortex, is relayed to the parastriate area (19), from where the efferent path Medial rectus travels to the Edinger–Westphal nucleus Medial rectus via the occipitomesencephalic tract and Accessory Ciliary ganglion Accessory the pontine centre for convergence. Oxford: Blackwell Scien frst a rapid dilatation of the pupil due to augmentation of tifc, 1973. The pupil as indicator of the sensory apparatus of the eye connects to the brain via retinal activity. Positron emission tomographic centre and it also connects to visual association areas. Functional brain imaging studies of cortical mecha for the pupillary light reflex. Refractive Errors of the Eye 70 this page intentionally left blank Chapter 5 Elementary Optics Chapter Outline Properties of Light 39 Refection at an Irregular Surface 42 Electromagnetic Spectrum 39 Refection at a Smooth Surface: Plane, Concave and Convex Wave Theory of Light 40 Mirrors 42 Interference, Diffraction and Polarization 40 Refraction 44 Rays of Light and Images 41 Plane Lamina 44 Refection 42 Prisms 45 Laws of Refection 42 Lenses 45 this chapter aims to impart information about the nature as sunlight, can be split into its component colours by and property of light to create a foundation of basic passing it through a suitable prism or diffraction grating. Clinical applications include prescription rays differing from each other in wavelength. Of these, of spectacles, calculation of intraocular lens power, surgi some colours are visible and appear to the majority of cal correction of refractive errors, imaging of the eye and people as pure colours—red, orange, yellow, green, blue, ophthalmic instrumentation, etc. These Optical radiation is a part of the electromagnetic spectrum are normally absorbed by the human crystalline lens, but and lies between X-rays and microwaves. Few perceptive, newly apha this is further subdivided into clusters or wavebands each kic patients have been observed to remark that ‘everything consisting of radiations which elicit similar biological looks bluer after the operation’. The cornea also absorbs long wavelengths in the tints for glass and plastic lenses are now available. Light refected from surfaces such as snow, a fat road and the same is true of the retinal pigmentary epithelium at or smooth water is generally horizontally polarized. Intraocular lens implants, made up of sports, skiing, golfng, cycling and jogging. In view of recent evidence and is diagrammatically shown as a straight, arrowed line that wavelengths of 350–441 nm are most likely to cause or a ray. Observations of the behaviour of light have shown retinal damage in routine environmental conditions, there is that light in fact travels in waves and wavefronts similar to the possibility that in future intraocular lenses will be pro ripples created by throwing a stone in a pool of water. Ordinary glass of the wave from the baseline and any portion of the cycle used for spectacles absorbs rays beyond 350 nm. Based on the principles highlighted above, Interference, Diffraction and Polarization special protective glasses designed to reduce the exposure of the eyes to harmful radiation are available. The most If two waves of equal wavelength are in phase and travel commonly used glass was Crookes B and C, but many other ling together, they may be summated to result in a resultant Chapter | 5 Elementary Optics 41 wave of amplitude equal to the sum of the two and this is known as constructive interference (Fig. If the two waves are out of phase by half a cycle and are of equal amplitude, the trough B of one will correspond with the crest of the other and they will cancel each other out, resulting in a fat or no wave which is called destructive interference (Fig. Screen When the path of a wavefront is blocked by an obstruc tion which contains a narrow opening or an edge, the wave motion passes across and spreads out on the other side as if the obstruction behaves as a new source for producing secondary wavefronts. In certain situations, the individual waves lie parallel to each other and move in the same plane; this is termed as polarized light. Light can also be polar are out of phase with the primary waves and lead to ‘blurring’ of the image ized in ordinary circumstances under natural conditions produced on a screen. When polarization occurs in this fashion, ted in straight lines, so that it may be imagined as coming the plane of polarization of the refected light is parallel from the source as an immense number of diverging with the surface of the refecting material. Every point on utilized in the making of three-dimensional movies and the such a ray represents, or is the image of, the point of light scanning laser polarimeter. Beyond the cardboard hold up a white screen (B) so that the cardboard is between the screen and the candle. A dim image (D) of the fame will be thrown upon the screen, and it will be noticed that it is upside down so that an inverted image of the fame is formed. This is due to the fact that the cardboard cuts off all the rays of light from the candle, except those that can pass through the hole. The image is dim because only a few rays of P R light can pass through the small hole. If a dozen holes are made, a dozen images appear and if the holes are close together the images will overlap. If a large hole is made, many more r i rays can pass through so that many images overlap and all resemblance to the original fame is lost, and part of the screen becomes uniformly illuminated. If the velocity is less in one medium than in Refection at an Irregular Surface another, the frst medium is said to be optically denser than the second. When light travelling in one medium When parallel rays of light strike an irregular surface, they meets another medium, its behaviour at the interface are refected and scattered in many directions. It is by this phenomenon that most non be absorbed by the second medium, may pass through it, self-luminous objects such as clothes, furniture, etc. A perfectly smooth refecting surface, with no surface three in different proportions as happens when optical irregularities to cause diffuse refection, is an ideal mirror radiations fall on the cornea. If the second medium is which itself would be invisible and only the image formed opaque, none of the light is refracted and all the light in the mirror by light refected from it would be visible. Plane Mirrors Before it meets the surface it is called an incident ray; If P (Fig. The brain assumes that an object is present in the to a greater or lesser extent at all interfaces even if most of the light is transmitted or absorbed. This is how a window or door pane made of clear glass and a black P V R T curtain can be seen. A mirror is a type of interface specially designed to maximize refection by having a highly polished smooth p v surface. In other words, if the observer actually goes opposite direction are negative; and (iii) the image size to the point p behind the mirror, there is no real image there is positive for erect images and negative for inverted and it cannot be captured on a screen. Moreover, the size of the image is equal to that of the the refecting surface lying along the inside of the curve. Now it is found that all rays parallel to the Spherical Mirrors axis cut the axis at the same point, F, and this point bisects Concave or convex mirrors form part of a sphere. This point is called the principal focus of the metric centre of the refecting surface of the mirror is called mirror. A ray parallel to the principal axis which is reflected If the object were situated between F and P (Fig. A ray from the top of the object going through the an object behind the mirror, much as they do with a plane centre of curvature which is reflected back along its mirror.

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Type of indicator : Rate-based process indicator Numerator : Number of cirrhotic patients with clinically apparent ascites had diagnostic abdominal paracentesis performed within (≤) 48 hours of admission Denominator : Total number of cirrhotic patients with clinically apparent ascites admitted Formula : Numerator x 100 % Denominator Standard : ≥ 80% Data Collection : 1 erectile dysfunction drugs market buy kamagra super 160mg visa. Where: Data will be collected in Liver/ Hepatology Ward or wards that cater for the above condition impotence in men over 50 purchase kamagra super mastercard. Remarks : Indicator 4 : Individual Discipline : Hepatology Name of indicator : Percentage of cirrhotic patients admitted with clinically apparent ascites given advice on low salt diet Dimension of Quality : Customer centeredness Rationale : 1 smoking and erectile dysfunction statistics cheap kamagra super 160mg without a prescription. All cirrhotic in-patients with clinically apparent ascites require salt restriction as well as other management of ascites impotence 16 year old buy kamagra super with a visa. Definition of Terms : Clinically apparent ascites: Flank dullness which is greater/ higher than usual and “shifting”. Type of indicator : Rate-based process indicator Numerator : Number of cirrhotic patients admitted with clinically apparent ascites given advice on low salt diet Denominator : Total number of cirrhotic patients admitted with clinically apparent ascites Formula : Numerator x 100% Denominator Standard : ≥ 80% Data Collection : 1. Where: Data will be collected in Liver/ Hepatology ward or wards that cater for the above condition. Patients with Acute Liver Failure or Acute on Chronic Liver Failure that satisfies transplant criteria or have poor prognostic markers have high mortality rates without liver transplant. Liver Transplant Team: the members are medical professionals with different expertise which may include doctors, nurses and other related health care personnel that involved in pre, during and post procedure care. Adult Acute Liver Failure or Acute on Chronic Liver Failure patients who were admitted and satisfied transplant criteria (based on the King’s College criteria or other criteria/ prognostic markers if applicable). Adult acute liver failure or acute on chronic liver failure patients who were accepted for transplant by the Transplant Team. Type of indicator : Rate-based process indicator Numerator : Number of patients with Acute Liver Failure or Acute on Chronic Liver Failure completed assessment within (≤) 48 hours of listing for liver transplant by the Transplant Team Denominator : Total number of patients with Acute Liver Failure or Acute on Chronic Liver Failure listed for liver transplant by Transplant Team Formula : Numerator x 100% Denominator Standard : ≥ 80% Data Collection : 1. Timely treatment in patients with significant liver disease prevents long term liver complications and use of more health resources. Definition of Terms : Assessment: Depend on the patient and treatment characteristics. Appointment: Time taken from the date of referral received to the date of first consultation with the doctor. This will ensure optimal clinical outcome with acceptable cost and side effect risks. Definition of Terms : Treatment counselling: Patient score ≥80% from a standardised survey form that filled up by the patient/ care taker (for patients who are not able to organise their medication schedule). Remarks : Indicator 5 : Individual Discipline : Infectious Disease Indicator : Percentage of patients started on carbapenam* in the Infectious Disease discipline who have a documented review within (≤) 72 hours of initiation Dimension of Quality : Effectiveness Rationale : 1. Definition of Terms : Documented review: Documented evidence that patients started on carbapenam in the Infectious Disease discipline are reviewed for continuation, cessation or de escalation within (≤) 72 hours of initiation. Patients died or transferred out of the hospital before 72 hours of initiation of carbapenam 2. Type of indicator : Rate-based process indicator Numerator : Number of patients started on carbapenam in the Infectious Disease discipline who have a documented review within (≤) 72 hours of initiation Denominator : Total number of patients started on carbapenam in the Infectious Disease discipline Formula : Numerator x 100 % Denominator Standard : ≥ 80% Data Collection : 1. Remarks : *The choice of antibiotic may vary depending on the antibiotic use and resistance data of the hospital. Definition of Terms : Screening for tuberculosis: this includes symptom screening and if necessary chest x-ray. Remarks : Indicator 2 : Departmental Discipline : Nephrology Name of indicator : Occurrence of peritonitis in adult patients on chronic peritoneal dialysis Dimension of Quality : Safety Rationale : 1. It causes pain, suffering and impacts on the workload of the haemodialysis unit as the patient may have to go on acute or permanent haemodialysis. Definition of Terms : Peritonitis: Present of at least 2 of the following criteria: 1. White cells in the peritoneal fluid of more than 100 cells/ml with at least 50% polymorphs. Where: Data will be collected in Nephrology wards or wards that cater for the above condition. Remarks : <1 case per 24 patient-months Indicator 3 : Departmental Discipline : Nephrology Name of indicator : Percentage of diabetic nephropathy patients with acceptable blood pressure control (≤ 130/80 mmHg) as measured in Nephrology Clinic Dimension of Quality : Effectiveness Rationale : 1. All patients with diabetic nephropathy on follow-up in Nephrology clinic in hospitals with resident Nephrologists. Remarks :  It is suggested that 25% sampling (random) is applied to the total number of patients seen at the Nephrology Clinic. The living donor kidney transplantation rate in Malaysia is less than two per million populations. The aim of this indicator is to ensure that the living donor transplantation is actively explored in appropriate patients. Definition of Terms : Documented: Documentation using a special form documenting a formal discussion performed. Where: Data will be collected in Nephrology Clinic/ Nephrology wards or wards that cater for the above condition. Control of hypertension depends on multiple factors including drug and non drug components. Reference: Clinical Practice Guidelines on the Management of Chronic Kidney Disease in Adults. Patients with albuminuria/ proteinuria due to non-diabetic nephropathy or structural abnormalities. Patients who have clinical contraindications or developed adverse clinical affects to either agents. There are wide varieties of indications for a neurology referral such as headache, epilepsy, movement disorders, entrapment neuropathy, and others. Therefore, early assessment will be able to make a neurology diagnosis, initiate proper investigations and hence starting appropriate treatment. It has been a department/ unit policy to review a newly referred case as early as possible. However, the appointment given is depends on the number of doctors and the work load of the neurology clinic in the respective hospitals. Type of indicator : Rate-based process indicator Numerator : Number of non-urgent cases that were given appointment for first consultation within (≤)12 weeks at Neurology Clinic Denominator : Total number of non-urgent cases referred to Neurology Clinic Formula : Numerator x 100% Denominator Standard : ≥ 85% Data Collection : 1. Who: Data will be collected by Officer/ Nurse/ Assistant Medical Officer in charge. Early referral to neurology team will ensure initiation of appropriate management and prevention of stroke complications. The long-term management includes secondary stroke prevention and rehabilitation process. Early neurological attention in acute stroke is related to better functional outcome and shorter hospitalization. Other cause is a thromboembolic phenomenon usually from cardiac (cardioembolic stroke). Neurology Consultation within (≤) 24 hours of referral: Time taken from the time patient was referred to Neurology team to the time patient was seen by the team (at least seen by the medical officer from Neurology team and discussed verbally or via phone consultation. Acute onset ischaemic stroke patient admitted for further management and referred for neurology consultation. Where: Data will be collected in Neurology wards or wards that cater for the above condition. Remarks : Indicator 4 : Individual Discipline : Neurology Name of indicator : Percentage of patients with Blepharospasm and Hemifacial Spasm who did not develop ptosis after 4 weeks of Botulinum Toxin Therapy Dimension of Quality : Effectiveness Rationale : 1. Blepharospasm is a neurological condition characterized by forcible closure of the eyelids. Oral medications such as muscle relaxation did not show significant clinical response and also cause untoward side effects. It is generally accepted that botulinum neurotoxin injections are the most effective treatment available for the reduction of symptoms. The presence of complications of botulinum toxin injection will reflect the incompetency of the injection technique, the inadequacy of training and skills as well as the ineffectiveness of the treatment. Definition of Terms : Blepharospasm: Abnormal involuntary and sustained contractions of the muscles around the eyes (orbicularis oculi). Hemifacial Spasm: Abnormal involuntary and sustained contractions of the muscles on one side of the face. Indicator 5 : Individual Discipline : Neurology Name of indicator : Percentage of Parkinson’s disease patients initiated on appropriate treatment within (≤) 12 weeks of referral to Neurology services Dimension of Quality : Customer centeredness Rationale : 1. In addition, neuro-imaging studies of brain show that dopamine may decline as much as 10% per year in people with Parkinson’s disease. However, dopamine agonists are inferior to levodopa in controlling motor symptoms.

There they undergo acylation reactions and are essentially consumed at that site erectile dysfunction questions purchase kamagra super 160 mg free shipping, causing the damage that may eventually lead to how to avoid erectile dysfunction causes generic kamagra super 160 mg without prescription pulmonary oedema erectile dysfunction tea kamagra super 160 mg low cost. After an asymptomatic or latent period of 20 minutes to impotent rage definition kamagra super 160mg free shipping 24 hours (depending on the exposure dose and physicochemical properties of the agent), fluid leakage into the pulmonary interstitium decreases compliance, producing a stiff lung and increasing complaint of tight chest, shortness of breath, and dyspnoea. Fluid eventually invades the alveoli and produces clinically evident pulmonary oedema. Pathology the outstanding feature of acute lung injury caused by lung-damaging agents is massive pulmonary oedema (Figure 5. This is preceded by damage to the bronchiolar epithelium, development of patchy areas of emphysema, partial atelectasis, and oedema of the perivascular connective tissue. Oedema fluid, usually frothy, pours from the bronchi and may be seen escaping from the mouth and nostrils. With exposure to very 79 | C h a p t e r 5 – L u n g d a m a g i n g (c h o k i n g) a g e n t s high concentrations, death may occur within several hours; in most fatal cases pulmonary oedema reaches a maximum in 12 hours, followed by death in 24 to 48 hours. If the casualty survives, resolution commences within 48 hours and, in the absence of complicating infection, there may be little or no residual damage. The lungs are hyperinflated due to the presence of pulmonary oedema and show focal parenchymal haemorrhage. Clinical effects Exposure to high concentrations of lung-damaging agent may irritate moist mucous membranes, depending on the agent’s reactivity and solubility in water. A transient burning sensation in the eyes with lacrimation may coexist with early onset cough and a substernal ache with a sensation of pressure. Irritation of the larynx by very large concentrations of the agent may lead to sudden laryngeal spasm and death. Pulmonary oedema follows a clinically latent period of variable length that depends primarily on the intensity of exposure but also partly on the physical activity of the exposed individual. After the latent period, the 81 | C h a p t e r 5 – L u n g d a m a g i n g (c h o k i n g) a g e n t s patient experiences worsening respiratory distress that at first is unaccompanied by objectively verifiable signs of pulmonary damage, but may progress relentlessly to pulmonary oedema and death. The most prominent symptom following the clinical latent period is dyspnoea, perceived as shortness of breath, with or without chest tightness, and in the initial stages there may be no objectively verifiable signs of pulmonary damage. The build-up of fluid in the lungs has two clinically pertinent effects: (1) Developing pulmonary oedema interferes with oxygen delivery to alveolar capillaries and may lead to hypoxemia. If a sufficient percentage of haemoglobin is non-oxygenated, cyanosis will become apparent. Death results from respiratory failure, hypoxemia, hypovolemia, or a combination of these factors. Hypoxia and hypotension may progress particularly rapidly and suggest a poor prognosis. The development of symptoms and signs of pulmonary oedema within four hours of exposure is an especially accurate indicator of a poor prognosis; in the absence of immediately available intensive medical support, such patients are at high risk of death. Complications include infection of damaged lungs and delayed deaths following such respiratory infections. Differential diagnosis Phosgene is distinguished by its odour, its generalised mucous membrane irritation in high concentrations, dyspnoea, and pulmonary oedema of delayed onset. Riot-control agents produce tearing, along with burning sensation and pain, predominantly in the eyes, upper airways, mucous membranes, and skin. This irritation is typically more intense than that caused by phosgene and is unaccompanied by the distinctive odour of phosgene. However, their other characteristic effects (for example, muscle twitching and miosis) distinguish nerve agent toxicity from organohalide inhalation injury. Vesicants usually produce a delayed respiratory toxicity associated predominantly with the central, rather than the peripheral, airways. Vesicant inhalation severe enough to cause dyspnoea typically causes signs of airway necrosis, often with pseudomembrane formation and partial or complete upper airway obstruction. Finally, pulmonary parenchymal damage following vesicant exposure usually manifests itself as haemorrhage rather than pulmonary oedema. Clinical investigations Sophisticated laboratory studies are of limited value in the immediate care of an exposed, injured individual. The following studies, however, are of some predictive value in determining the severity of exposure and the likely outcome. The presence of “batwing” infiltrates suggests pulmonary oedema secondary to toxic alveolar-capillary membrane damage. As radiological changes may lag behind clinical changes by hours to days, the chest radiograph may be of limited value, particularly if normal. B) Arterial blood gases Hypoxia often results from exposure to lung-damaging materials such as chlorine. Measurement of the partial pressure of oxygen (pO2) is a sensitive but non-specific tool in this setting; both the central and peripheral effects of pulmonary intoxicants may produce hypoxia. At 4 to 6 hours, normal arterial blood gas values are a strong indication that a particular exposure has little likelihood of producing a lethal effect. This non-specific test helps to assess the degree of airway damage and the effect of bronchodilator therapy. Decreased lung compliance and carbon dioxide diffusing capacity are particularly sensitive indicators of interstitial fluid volume in the lung, but are complex tests for hospital use only. Ventilation/perfusion ratio (V/Q) scanning is very sensitive but is nonspecific and for hospital use only. Medical Management a) Termination of exposure Terminate exposure as a vital first measure. This may be accomplished by physically removing the casualty from the hazardous environment or by respiratory protection with a properly fitting respirator. Decontamination of liquid agent on clothing or skin terminates exposure from that source. Establishing an airway is especially crucial in a patient exhibiting hoarseness or stridor; such individuals may face impending laryngeal spasm and require intubation. Because of the danger of hypotension induced by pulmonary oedema or positive airway pressure, accurate determination of 84 | C h a p t e r 5 – L u n g d a m a g i n g (c h o k i n g) a g e n t s the patient’s circulatory status is vital, not just initially, but also at regularly repeated intervals and whenever indicated by the clinical situation. Carefully replace intravascular volume as required to maintain haemodynamic stability. Physical activity in a symptomatic patient may precipitate acute clinical deterioration and even death. This is true whether or not the patient has respiratory symptoms and whether or not objective evidence of pulmonary oedema is present. Physicians should consider the early administration of such drugs whilst weighing up the known side effects of inhaled steroids. Unless super-infection is present, secretions present in the airways of phosgene casualties are usually copious and watery. They may serve as an index of the degree of pulmonary oedema and do not require specific therapy apart from suction and drainage. Antibiotics should be reserved for those patients with an infectious process documented by sputum gram-staining and culture. Bronchospasm may occur in individuals with reactive airways, and these patients should receive beta-adrenergic bronchodilators. Parenteral administration is the preferred route of steroid administration as inhaled routes may result in inadequate distribution to damaged airways. Methylprednisolone, 700 to 1000 mg, or its equivalent, may be given intravenously in divided doses during the first day and then tapered during the duration of the clinical illness. The increased susceptibility to bacterial infection during steroid therapy mandates careful surveillance of thepatient. Intubation with or without ventilatory assistance may be required, and positive pressure may need to be applied during at least the end-expiratory phase of the ventilator cycle. Urgent intravenous administration of either crystalloid or colloid (which in this situation appear equally effective) should be commenced. Triage a) Within 12 hours of exposure A patient with pulmonary oedema is classified immediate only if intensive pulmonary care is immediately available. A delayed patient is dyspnoeic without objective signs and should be observed closely and re-triaged hourly. An asymptomatic patient with known exposure should be classified minimal and observed and re-triaged every 2 hours.

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