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By: Bruce Alan Perler, M.B.A., M.D.

  • Vice Chair for Clinical Operations and Financial Affairs
  • Professor of Surgery

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0002711/bruce-perler

We hope that this knowledge has permitted better surgical management of the victims of armed confict and other situations of violence where the weapons of war are used medications with gluten buy 3 ml bimat visa. During armed confict medications to treat bipolar purchase discount bimat online, all the usual trauma of peacetime continues unabated and natural catastrophes occur as well treatment nail fungus order bimat. Armed confict itself provokes blunt injuries and burns treatment lichen sclerosis discount bimat 3 ml otc, and trauma that are specifc to weapons and the circumstances of warfare. More specifcally, combat involves penetrating and blast injuries; these will be the major focus of this book. Modern armed confict causes specifc penetrating and blast injuries, as well as blunt and burn trauma. Severe injury due to blunt trauma may be more difcult to detect than in cases of penetrating trauma, and X-ray diagnosis and other more sophisticated technologies are more valuable for patient assessment. Road trafc crashes Military vehicles often drive at high speed over difcult terrain where safe roads do not exist. In addition, the environment of any accident may be hostile (presence of 3 enemy forces, minefelds, etc. Collapsed buildings and falls the collapse of bombed buildings will cause blunt and crush injuries to anyone inside. The explosion of the mine overturns or destroys the vehicle and people are thrown out and onto the ground, thus sufering blunt injuries. Beatings Mistreatment of prisoners, ofcials, suspected sympathizers or other civilians is, alas, all too common. When the projectile enters the human body, it releases energy to the tissues thus causing a wound. There are two types of wounding projectiles: bullets and metallic fragments (or splinters, shards, and shrapnel)2. Fragment wounds Exploding bombs, shells, rockets and grenades, submunitions (cluster bomblets) and some landmines, produce metal fragments from the weapon casing (primary projectiles). In many modern weapons, however, the inner lining of the casing is scored, creating weak points that break of easily on explosion. This generates a controlled fragmentation of large numbers of pre-formed fragments that are regular in size and shape, and usually less than 1 g in weight. In other, usually improvised bombs and explosive devices, nails, bolts, steel pellets or other metallic debris surround the explosive material. The term originally referred only to the metal balls dispersed when a shrapnel shell bursts, but is often used to describe metal fragments intentionally included in explosive devices. For shells, bombs or other munitions, the technical term for these particles is fragments, splinters or shards, fragments being the preferred name in scientifc documents and the term that is used in this manual. At very close range, multiple highenergy fragments combined with the blast efect create mutilating injuries and are often fatal. Explosions may cause stones or bricks to break up, shatter glass panes, or the force of the blast wind may transport other debris, also producing penetrating fragments (secondary projectiles), as described in Section 3. Fragment wounds are usually multiple and the wound tract is always widest at the entry. Bullet wounds seen in the injured are usually single with a small entry; multiple bullet injuries are more likely to kill. According to international humanitarian law both customary and conventional the use of bullets that expand or fatten easily in the human body is prohibited during armed confict. This fundamental rule is based on the general principles of international humanitarian law, according to which it is sufcient to disable the greatest possible number of men and That this object would be exceeded by the employment of arms which uselessly aggravate the sufering of disabled men or render their death inevitable. Unexploded ordnance is often left on the battlefeld and has similar injuring efects as fragmentation mines (the lethal remnants of war consisting of cluster bomblets, bombs and shells that did not explode when fred). These weapons continue to kill and injure large numbers of civilians long after the end of hostilities and have widespread humanitarian and economic repercussions. Patterns of injury Anti-personnel mines cause three distinct patterns of injury according to the blast efect or the production of fragments. The explosion and local primary blast efect cause a traumatic amputation or severe injury of the contact foot and leg. There may be wounds to the other leg, genitals, abdomen or pelvis, and the contralateral arm. The severity of the wound depends on the amount of explosive in the mine compared to the body mass (Figure 3. Pattern 2 A person touches the tripwire attached to a fragmentation mine, which provokes its detonation. Fragmentation mines cause the same injuries as other fragmentation devices, such as bombs or grenades, and the severity of the injury depends on the distance of the victim from the explosion. The explosion causes severe injury to the hand and arm, and frequent injuries sufer less damage than deep-tissue planes. The wave causes rapid and large changes in the outside atmospheric pressure: the positive pressure shock wave is followed by a negative pressure phase (Figure 3. Rupture of the lung alveoli and their capillaries (?blast lung) is the most lethal injury amongst survivors. In addition, the blast wind may mobilize various objects (secondary missiles) that then cause penetrating wounds. It can cause total body disintegration in the immediate vicinity of the explosion; traumatic amputations and evisceration further away. Quaternary Miscellaneous types of harm due to burns, asphyxia from carbon monoxide or toxic gases, or the inhalation of dust, smoke or contaminants. The various injuries caused by major blasts cover a whole spectrum of trauma and many patients sufer several injuries from a variety of efects: i. Other situations of blast injuries the blast wave travels more rapidly and much further in water than in air. A fuel air explosive the liquid explosive material is dispersed in the air like an aerosol and then ignited also tends to bring about pure primary blast injury and quaternary efects due to the consumption of all oxygen in the nearby air. The blast efect of a marine mine exploding below an icy surface, or the deck slap of a ship hit by a torpedo, produces a shock wave that can severely fracture the bones of anyone on deck or inside the ship. Similarly, some anti-tank mines send a blast wave through the foor of the vehicle causing closed fractures of the foot and leg. The foot appears like a bag of bones inside intact skin, which was described in World War I as pied de mine?: a mine foot. Anti-personnel blast mines have a local blast efect, vaporizing the tissues of the contact foot, as described previously. Bombing may start secondary fres in buildings and an anti-tank mine may ignite the petrol tank of a vehicle. Some types of anti-personnel blast mines provoke burning as well as traumatic amputation of the limb. Certain weapons cause specifc burns: napalm and phosphorus bombs, magnesium fares and decoys. Nonetheless, this absolute prohibition cannot entirely exclude that a State or a nonState armed group resort to using them. A bomb surrounded by radioactive material the so-called dirty bomb is not a nuclear bomb. The explosion is caused by conventional means but, depending on the force of the explosion, radioactive material may be spread over a wide area. The bombing of nuclear medicine and other laboratory facilities, or nuclear power plants, may also release radioactive material into the atmosphere. While standard surgical techniques will sufce to treat simple wounds, the management of war wounds produced by high-energy weapons is based on an understanding of the mechanisms by which projectiles cause injury: wound ballistics. Only by understanding certain physical phenomena can the surgeon appreciate the diferent varieties of wounds seen in armed confict and the diference between these wounds and the trauma that is seen in everyday civilian practice. Although the study of ballistics may be interesting in its own right, the clinician does not always know what weapon inficted the injury; and never knows the energy available at point of impact. One can only estimate the transfer of energy in the tissues from the extent of tissue damage. The study of ballistics gives us an understanding of the basic mechanisms at work during wounding. The importance of this knowledge lies in the fact that projectile injuries should be neither undernor over-treated. The clinical assessment of the actual wound is the most important factor determining management, and an understanding of ballistics allows the surgeon to better understand the pathology and assess the injuries that he sees, rather than explain every wound and determine specifc treatment.

Syndromes

  • Bone disease (osteoporosis, kyphoscoliosis, fractures)
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Porous substrates tend to symptoms type 1 diabetes best 3ml bimat absorb the dye medication 3 checks buy bimat toronto, retion is observed medicine quiz order genuine bimat on line, the solution or the validation matrix will sulting in a lack of contrast between the friction ridge detail require further evaluation medicine 750 dollars purchase bimat 3 ml amex. Because of the blue-black color with the application technique and the reaction(s) with the of the dye stain, there will be a lack of contrast between substrate and matrix before applying them to evidence. It is recomReview the material safety data sheets for safety, handling, mended that other processing techniques be used on and storage information. The reagent solution conDried Sudan black-processed prints have been lifted using sists of 15 g of Sudan black dissolved in 1 L of ethanol or conventional lifting tape (as used with the powder processmethanol, creating a blue-black color solution, which is ing technique). Stock Solution: 25 g ninhydrin dissolved in 225 mL absolute ethanol, 10 mL ethyl acetate, 25 mL glacial acetic acid. It is recommended that the immersion technique be used to prevent inhalation of airborne 7. Restore total volume to 1 L Dissolve 30 g silver nitrate in 100 mL distilled water and with high-purity water. Stock Solution #1: 30 g ferric nitrate nonahydrate dissolved in 900 mL distilled water. Shelf life may be Working Solution: Add 1 part of stock solution #2 to 99 several months. Stock Solution #2: 4 g n-Dodecylamine acetate dissolved Application in 1 L distilled water. Soak for 5 secPrewashing: Porous items should be washed with high-puonds in 2% (v/v) 3-aminopropyltriethoxysilane in acetone. Colloidal Gold: Soak items in colloidal gold solution for 5?15 Colloidal Gold Solution minutes with mild agitation. Stock Solution #1: 10% (w/v) tetrachlorauric acid in highIn-Between Rinsing: Rinse briefy in high-purity water. In-Between Hydroquinone Rinsing: Rinse for 2?5 minutes Stock Solution #2: 1% (w/v) sodium citrate in high-purity in hydroquinone rinsing solution. The reviewers critiquing this chapter were Christophe Once both solutions reach 60 C, rapidly add working soluChampod, Sue Manci Coppejans, Christine L. Utilization of Triketohydrindene Hydrate for the Detection of Proteins and Their Cleavage Products. Presented at the 17th Offce Police Scientifc Development Branch: Sandridge, Meeting of the International Association of the Forensic U. Fingerprint Development by Ninhydrin and Its of Water Soluble Protein Dye for the Enhancement of FootAnalogues. In Advances in Fingerprint Technology; Lee, wear Impressions in Blood on Non-Porous Surfaces?Part H. Superglue Treatment of Crime Scenes?A Trial of the Effectiveness of the Mason Vactron 7?56 Latent Print Development C H A P T E R 7 Boysen, T. A Comparative Examination of Several Amino Acid Reagents for Visualizing Amino Acid (Glycine) on PaDavies, P. An Immunocolloid Method for ment of Ninhydrin Developed Fingerprints Using Group 12 the Electron Microscope. Laser Detection of Latent A New Reagent for the Detection of a-Amino Acids and Fingerprints: Ninhydrin. The Transparent, Liquid Adhesive, Latent gerprints: Ninhydrin Followed by Zinc Chloride. Thesis, the Royal munogold?Silver Staining: New Method of Immunostaining Holloway College, University of London, 1972. Die Sichtbarmachung der Adand Enhancement of Latent Fingerprints on Semi-Porous sorption von Metallkolloiden an Eiwei? Conservation of Amino-Acid Analysis of Latent Print Residue; Forensic Science Service: Chromatograms. Evaluation of Gun Blueing rylate Fuming in a Vacuum Cabinet to a Humidity Fuming Solutions and Their Ability to Develop Latent Fingerprints Chamber. Superglue Fingerprint Development Atmospheric Pressure and High Humidity, or Vacuum Lee, H. In Advances in Fingerprint Technology, 2nd sium on Fingerprint Detection and Identifcation; Ne?urim, ed. Deposition Technique to the Development of Fingerprints In Encyclopedia of Forensic Science; Siegel, J. Sequencing of Reagents for Vacuum Coating Technique for the Development of Latent the Improved Visualization of Latent Fingerprints. A Comparative Study of Three Synthesis of Ninhydrin Analogues and Their Application to Techniques: Aluminium Powdering, Lead Powdering and Fingerprint Development: Preliminary Results. Offce Police Scientifc Development Branch: Sandridge, Photoluminescent Enhancement of Ninhydrin Developed U. Dimensional Footwear and Fingerprint Impressions Using B25: 1,2-Indanedione: Is it a Useful Fingerprint Reagent? Processes Involved in the Development of Latent Fingerprints Using the Cyanoacrylate Fuming Kobus, H. Discussion of Studies on Chloride, Urea, Glucose, Uric Polyethylene Comparing Vacuum Metal Deposition to Acid, Ammonia?Nitrogen, and Creatinine. Controlled Environmental Conditions of Nitrogen and Minerals in Human Subjects, with Particular Reference to Magora, A. Contaminated Polythene Bags Prior to Fingerprint Development by Cyanoacrylate Fuming. Analysis of Human Sweat Proteins by TwoDimensional Electrophoresis and Ultrasensitive Silver Mitsui, T. Direct TemperatureControlled Trapping System and Its Use for the Gas ChroMenzel, E. Laser Detection of Latent Fingermatographic Determination of Organic Vapor Released prints?Treatment with Fluorescers. Development of Latent Fingerprints on Unfred Cartridges by Palladium Deposition: A Surface Nicolaides, N. Fatty Acids of Wax Esters and Sterol Esters from Vernix 7?62 Latent Print Development C H A P T E R 7 Caseosa and from Human Skin Surface Lipid. Cutaneous Bacteria (Staphylococcus Epidermis, Propionibacterium Acnes, and Propionibacterium Granulosum). In Physiology, BiochemChemical Composition of Human Surface Lipids from istry, and Molecular Biology of the Skin, 2nd ed. In Encyclopedia of Forensic Metal Deposition with Small Particle Reagent for the DeScience; Siegel, J. Investigations of the Reaction Mechanisms of 1,2Biochemistry, and Molecular Biology of the Skin, 2nd ed. Does Superglue Hinder Traditional Firearms the Development of Latent Fingerprints. Advanced Solvent-Free Application of Ninhydrin for Detection of Latent Fingerprints on Ruhemann, S. The Physiology, Pharmacology, and Biochemistry in Blood, Part I: the Optimization of Amido Black. Radicals and Anion Radicals from Electron Transfer and Solvent Condensation with the Fingerprint Developing Agent Soderman, H. The Physics of Fingerprints and Their DetecUnderstanding for Latent Friction Ridge Development. Excretion of to Detect Latent Fingerprints on Thermal Paper with o-Alkyl Amphetamines in Human Sweat. Development of Latent Prints with Titanium Technique for Bringing Out Latent Fingerprints on Paper: Dioxide (TiO2). Study of the Reaction Mechanism of 1,8A0571: 1,2-Indanedione as a Finger Mark Reagent OptimiDiazafuoren-9-one with the Amino Acid, L -Alanine. A Comparison of the Forensic Evaluation of 5-Methylthioninhydrin for the Detection of Light Sources: Polilight, Luma-Lite, and Spectrum 9000. Basic Photo Science: How Forensic Light Sources: Luma-Lite, Mini-Crimescope 400, Photography Works; Focal Press: London, 1977. Identifying the True Field Trial Comparing Two Formulations of 1,8-DiazafuorenInitiator in the Cyanoacrylate Fuming Method. Canada 2003, 26 the 2005 International Association for Identifcation Confer(2), 8?18.

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Coarcitation of aorta It is stenosis (constriction) of the aorta distal to medications jamaica cheap bimat 3ml with mastercard the left subclavian artery treatment 4 pink eye bimat 3 ml mastercard. Treatment Surgical by closed heart technique (excision of the coarcitation segment and end to symptoms meningitis purchase 3 ml bimat end anastomosis) 5 medicine journal impact factor buy bimat 3ml on line. Palliative operation: In Severe cases with cyanotic attacks in age below one year. Angina at rest It is a more severe stage of coronary atherosclerosis where anginal pain occurs at rest. Unstable angina It is a more severe stage of coronary atherosclerosis where anginal pain is prolonged, not relieved by rest or coronary vasodilators (considered as pre infarction syndrome) this case is accompanied with severe sweating and pallor. Rheumatic fever It is a widespread disease in lack of hygiene, malnutrition and overcrowdness. Left atrial fibrillation &loss of contractile element leads to thrombosis and stroke. Hemodynamics of Tricuspid and pulmonary valve affection They are rare to be affected by rheumatic fever, bust in most cases the affection is functional and not organic & in the form of stenosis. Heart failure Definition It is inability of the heart be perform its normal function. Congestive heart failure (both right and left side failure) Manifestations of right side heart failure 1. Cardiac Rehabilitation Definition Rehabilitation is a therapeutic process designed to facilitate maximal restoration of function. Each patient must be individually assessed to determine diagnosis, associated injuries, responses, and achievable goals. Patients and his family: Patients and his family must never be overlooked as members of prescribing team. The patient and his family must be made a ware of the program into which he is about to enter, with all its implications. Physician: the physician is the leader and coordinator of the team; he attends to all medical aspects of the individual case. Therapists: Occupational and physical therapists 67 In the treatment of physical disabilities the physical therapies have a similar ultimate goal, namely, to contribute to the restoration of the physical function of the patient. Social service: Social case work which helps the patient and his family to accept and adjust to the problems resulting from his disability. The program frequently begins in a hospital setting and continues on an outpatient basis after the patient is discharged over a period of 6-12 months. Phases of cardiac rehabilitation Cardiac rehabilitation services are divided into 3 phases beginning with phase 1 that is initiated while the patient is still in the hospital, followed by phase 2 that is a supervised ambulatory outpatient program spanning 3-6 months, and subsequently continuing into phase 3, a lifetime maintenance phase, in which physical fitness, as well as additional risk factor reduction, are emphasized. Basic Program Structure Traditionally cardiac rehabilitation is divided into three phases with essential medical, educational and exercise components being applied during each phase. Each patient rate of progression through these phases will vary depending on the nature and severity of illness, complications and rate of recovery. Phase I (Immediate inpatient phase) 68 It is the acute in hospital phase; it is usually 7-14 days in duration. The goals of rehabilitation during Phase (I): 1-To initiate early physical therapy activities which allow: aReturn to activities of daily living. During phase I the rate of progression of people who have had a myocardial infarction is slightly slower than for those who have had coronary artery bypass grafts. Mobilization of surgical patients usually starts earlier and intensity and duration of ambulation are more accelerated. Exercise hypotension (>20 mmHg drop in systolic blood pressure during exercise) 10. By 6-8 weeks the myocardial scar formation has taken place and the sternum is healed following surgery. Training Program: 1-Conditioning exercises: Rhythmic aerobic exercises as walking, jogging, swimming and rowing. Lower extremity aerobic exercise is accomplished with stationary equipment such as treadmills and bicycle ergometers. They found that cardiac rehabilitation patients return to work an average of almost 40 days sooner than non-rehabilitation patients. The role of physical therapist is to guide, instruct and follow up their patients who asked to keep in contact with the rehabilitation team. Table (5): Contraindications for Entry into Inpatient and Outpatient Exercise Programs. Resting systolic blood pressure >200 mmHg or resting diastolic blood pressure> 100 mmHg 3. Orthopedic problems that would prohibit exercise Outcomes of Cardiac Rehabilitation Training 1. This beneficial effect does not persist long-term after completion of cardiac rehabilitation without a long-term maintenance program. Therefore, exercise training must be maintained long term to sustain the improvement in exercise capacity. Improvement in the blood levels of lipids Improvements in lipid and lipoprotein levels are observed in patients undergoing cardiac rehabilitation exercise training and education. Exercise must be combined with dietary and medical interventions for required lipid control. Effect on body weight Optimal management of obesity requires multifactorial rehabilitation, including nutritional education and counseling, behavioral modification and exercise training. Effect on blood pressure Rehabilitative exercise training as a sole intervention has minimal effect; however, multifactorial intervention has been shown to have beneficial effects. Reduction in smoking Cardiac rehabilitation services with well-designed educational, counseling and behavioral modification programs result in cessation of smoking in a significant number of patients. Improved psychosocial well being Cardiac rehabilitation exercise and education services enhance measures of psychological and social functioning. Enhanced social adjustment and functioning Cardiac rehabilitation exercise training improves social adjustment and functioning. Return to work Cardiac rehabilitation exercise training exerts less influence on rates of return to work than on other aspects of life. Many non exercise variables also affect this outcome (eg, prior employment status, employer attitude, economic incentives). Reduced mortality Scientific data suggest a survival benefit for patients who participate in cardiac rehabilitation exercise training, but it is not attributable to exercise alone. Mode Aerobic exercise training includes walking, jogging, running, swimming and stationary bicycling or any combination of these activities. Intensity the intensity prescribed according to: 1-Target heart rate (training heart rate) which determined according to Karvonen formula as following: Target heart rate = Resting heart rate + 60%-80 %(Maximum heart rate resting heart rate) Maximum heart rate = 220age. Use this scale where 6 mean no exertion at all and 20 means a totally maximum effort. Exercise session consists of: AWarming-up: Applied for about 10 minutes in the form of light calisthenics and muscular stretching are performed to: 1Avoid muscle injury 2-Prepare cardiopulmonary system to exercise. BAerobic exercise: Applied for about 40 minutes in the form of walking, jogging and bicycling. DCooling down: Applied for 10 minutes in the same form of the applied aerobic exercises used during training. A-Right sided catheter and angiography Right sided catheter should be passed from femoral vein or anticubital vein to the interior vena cava or superior vena cava respectively to right atrium through the tricuspid valve to the right ventricle and to the pulmonary artery through the pulmonary valve in each chamber (Read the pressure and take blood sample for oxygen saturation analysis) at the end of the cauterization inject radio opaque dye to visualize big vessels and cardiac chambers (Cardiac angiography). B-Left sided catheter and angiography Left sided catheter should be passed from the femoral artery to the common iliac artery to the abdominal aorta to the thoracic aorta then to the arch of the aorta to the ascending aorta then to the left atrium through the aorta valve to the left ventricle through the mitral valve (Read the pressure and take blood sample for oxygen saturation analysis) at the end of the catheterization inject radio opaque dye to visualize the big vessels and the cardiac chambers (Cardiac angiography). C-Coronary angiography 1-Selective left coronary angiography Pass the catheter (as in left sided catheter) but from aorta to the left coronary ostium and inject dye to see anatomy of left coronary artery and its branches. Pleural effusion: obliteration of costophrenic angle and obliteration of lung and obliteration of lung zone, in massive pleural effusion there is shift of the mediastinum 2. Xray findings in common cardiac diseases 1Left atrial enlargement Straightening of the left border of the heart with enlargement the left atrial appendage (mitralization of the heart). Position of the six chest electrodes 80 Figure (16): Position of the six chest electrodes. The chest leads are V1: right 4th intercostal space; V2: left 4th intercostal space; V3: between V2 and V4; V4: mid-clavicular line, 5th space; V5: anterior axillary line, horizontally in line with V4; V6: mid-axillary line, horizontally in line with V4. Heart Rate In regular rhythm, the heart rate is calculated by counting the number of large square between two consecutive R waves, and dividing it into 300. Alternatively, the number of small squares between two consecutive R waves may be divided into 1500. Exercise Stress Test Definition 82 It is a safe relatively non-invasive and sensitive method of measuring cardiovascular and pulmonary responses to increased activity.

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  • Burning mouth syndrome- Type 3
  • Opitz syndrome
  • Niemann Pick disease, type C
  • Chromosome 6, monosomy 6q1
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