By P. Marcus. Hastings College.

Economies are globalizing discount generic endep canada, people are more likely to live in cities buy 25 mg endep with visa, and technology is evolving rapidly 25 mg endep amex. Demographic and family changes mean there will be fewer older people with families to care for them. People today have fewer children, are less likely to be married, and are less likely to live with older generations. By 2050, this number is expected to fell with surprising speed in many less developed nearly triple to about 1. Between 2010 and 2050, the number of older Most developed nations have had decades to people in less developed countries is projected to adjust to their changing age structures. In contrast, many less This remarkable phenomenon is being driven developed countries are experiencing a rapid by declines in fertility and improvements in increase in the number and percentage of older longevity. With fewer children entering the people, often within a single generation (Figure population and people living longer, older 2). For example, the same demographic aging people are making up an increasing share of the that unfolded over more than a century in total population. The Speed of Population Aging Time required or expected for percentage of population aged 65 and over to rise from 7 percent to 14 percent Source: Kinsella K, He W. In some countries, the sheer number of people entering older ages will challenge national infrastructures, particularly health systems. By the middle of this century, there could be 100 million Chinese over the age of 80. This is an amazing achievement considering that there were fewer than 14 million people this age on the entire planet just a century ago. Growth of the Population Aged 65 and Older in India and China: 2010-2050 Source: United Nations. Humanity’s Aging 5 Living Longer The dramatic increase in average life expectancy pathways. Less developed to noncommunicable diseases and chronic regions of the world have experienced a steady conditions. Even These improvements are part of a major earlier, better living standards, especially transition in human health spreading around more nutritious diets and cleaner drinking the globe at different rates and along different water, began to reduce serious infections and prevent deaths among children. Research for more recent periods shows a surprising and continuing improvement in life expectancy among those aged 80 or above. The progressive increase in survival in these oldest age groups was not anticipated by demographers, and it raises questions about how high the average life expectancy can realistically rise and about the potential length of the human lifespan. While some experts assume that life expectancy must be approaching an upper limit, 6 Global Health and Aging Figure 4. Living Longer 7 data on life expectancies between 1840 and 2007 global level, the 85-and-over population is show a steady increase averaging about three projected to increase 351 percent between 2010 months of life per year. The country with the and 2050, compared to a 188 percent increase for highest average life expectancy has varied over the population aged 65 or older and a 22 percent time (Figure 4). So far there is little evidence that life to increase 10-fold between 2010 and 2050. In many decreases in mortality rates among the oldest countries, the oldest old are now the fastest old. Percentage Change in the World’s Population by Age: 2010-2050 Source: United Nations, World Population Prospects: The 2010 Revision. Demographers and epidemiologists describe this Evidence from the multicountry Global Burden shift as part of an “epidemiologic transition” of Disease project and other international characterized by the waning of infectious and epidemiologic research shows that health acute diseases and the emerging importance of problems associated with wealthy and aged chronic and degenerative diseases. High death populations affect a wide and expanding rates from infectious diseases are commonly swath of world population. Over the next associated with the poverty, poor diets, and 10 to 15 years, people in every world region limited infrastructure found in developing will suffer more death and disability from countries. Although many developing countries such noncommunicable diseases as heart still experience high child mortality from disease, cancer, and diabetes than from infectious and parasitic diseases, one of the Figure 6. The Increasing Burden of Chronic Noncommunicable Diseases: 2008 and 2030 Source: World Health Organization, Projections of Mortality and Burden of Disease, 2004-2030. In direct bearing on the development of risk factors for 2008, noncommunicable diseases accounted for an adult diseases—especially cardiovascular diseases. Among the impairments or physical limitations at ages 80 or 60-and-over population, noncommunicable diseases older. Proving links between childhood health conditions But the continuing health threats from and adult development and health is a complicated communicable diseases for older people cannot research challenge. Older people account for a necessary to separate the health effects of changes growing share of the infectious disease burden in in living standards or environmental conditions low-income countries. However, older people and ignore the potential effects of a Swedish study with excellent historical data population aging. And, there is growing evidence A cross-national investigation of data from two that older people are particularly susceptible surveys of older populations in Latin America to infectious diseases for a variety of reasons, and the Caribbean also found links between early including immunosenescence (the progressive conditions and later disability. The older people in deterioration of immune function with age) the studies were born and grew up during times and frailty. Older people already suffering from of generally poor nutrition and higher risk of one chronic or infectious disease are especially exposure to infectious diseases. For survey, the probability of being disabled was more example, type 2 diabetes and tuberculosis are well- than 64 percent higher for people growing up in known “comorbid risk factors” that have serious health consequences for older people. A survey of seven urban centers in Latin counterparts in the developed world, and studies America and the Caribbean found the probability such as those described above suggest that they are of disability was 43 percent higher for those from at much greater risk of health problems in older age, disadvantaged backgrounds than for those from more often from multiple noncommunicable diseases. People now growing old in low- and middle- diet, and physical activity may have long-term health income countries are likely to have experienced more implications. Probability of Being Disabled among Elderly in Seven Cities of Latin America and the Caribbean (2000) and Puerto Rico (2002-2003) by Early Life Conditions Source: Monteverde M, Norohna K, Palloni A. Effect of early conditions on disability among the elderly in Latin-America and the Caribbean. New Disease Patterns 11 Longer Lives and Disability Are we living healthier as well as longer lives, or forward. National Institutes of Health, found among researchers, and the answers have broad surprising health differences, for example, implications for the growing number of older between non-Hispanic whites aged 55 to 64 people around the world. In general, the question is to look at changes in rates of people in higher socioeconomic levels have better disability, one measure of health and function. In the United States, between 1982 in education and behavioral risk factors (such as and 2001 severe disability fell about 25 percent smoking, obesity, and alcohol use) explained few among those aged 65 or older even as life of the health differences. With the levels of wealth, Americans were less healthy rapid growth of older populations throughout than their European counterparts. Analyses of the world—and the high costs of managing the same data sources also showed that cognitive people with disabilities—continuing and better functioning declined further between ages 55 and assessment of trends in disability in different 65 in countries where workers left the labor force countries will help researchers discover more at early ages, suggesting that engagement in about why there are such differences across work might help preserve cognitive functioning. American Journal of Public Health 2009; 99/3:540-548, using data from the Health and Retirement Study, the English Longitudinal Study of Ageing, and the Survey of Health, Ageing and Retirement in Europe. Dementia prevalence estimates vary considerably internationally, in part because diagnoses and reporting systems are not standardized.

The contribution of these professionals in dose optimization and radiation protection training would be very valuable purchase endep pills in toronto. Equipment characteristics Another important issue concerns the equipment characteristics generic endep 25mg otc. This is particularly obvious in interventional radiology performed in operating rooms purchase 10mg endep with visa. This activity is being used for more types of procedure and for patients presenting with more complex clinical circumstances. However, the optimization capacities of the equipment are all the more useful as the procedures get more complex and could lead to important patient and staff exposure reductions. To allow patient dose monitoring and establishment of dose alert values, the equipment must provide the kerma area product of the procedure. Finally, the equipment must be equipped with adequate collective shielding for staff protection. In operating rooms, where X ray units are mobile C-arms, no protective screen is systematically available. Hospitals must provide protection adapted to the types of procedure and to the operational work conditions. Staff dose monitoring Another point to be considered is the improvement of staff dose monitoring, especially in operating rooms. It is well known that personal dosimeters are not regularly worn in operating rooms. Additional monitoring for the eyes and hands, using ring rather than wrist dosimeters, is sometimes necessary, according to the risk analysis. Operators, surgeons or cardiologists are not always convinced of the use of dose monitoring and sometimes consider dose monitoring a ‘constraint’ and refuse it. Hand monitoring has often been refused on hygiene grounds even though dosimeters can now be sterilized. Staff dose monitoring in operating theatres is not harmonized at the international level. Dose measurement above the apron is sometimes associated with the dose measurement under the apron to calculate the effective dose. Repeated paediatric procedures The last important issue concerns procedures performed on children. Owing to the fact that their organs are in development and due to their long life span, the paediatric population is sensitive to ionizing radiation. Special care must be taken in justification and optimization when exposing children, especially in the case of repeated procedures. In neonatology, daily chest and abdomen X rays can be performed on very young children, often on premature babies, for weeks. In France in 2010, 50% of diagnostic procedures performed on children were dental examinations. Finally, the daily work of radiation protection actors has practically improved the situation in the medical field. Nevertheless, operating rooms remain places where basic radiation protection rules are rarely integrated into daily practice. Guidelines have already been developed [2, 4] and recommendations are available [5], but work still has to be done, in the near future, to practically improve radiation protection in operating rooms. Moreover, special attention should be paid to procedures performed on children, especially at the bedside and in dental radiology. Radiation protection is vital for all procedures performed under fluoroscopy guidance, including those performed in the endoscopy suite. Radiation protection in the endoscopy suite should follow published guidelines from the International Commission on Radiological Protection and the World Gastroenterology Organisation, which specifically address the issue of radiation protection for fluoroscopically guided procedures performed outside imaging departments and in the endoscopy suite. Recent studies have examined the issue of lifetime cumulative effective doses received by patients attending hospital with gastrointestinal disorders and have shown potential for substantial radiation exposures from gastrointestinal imaging, especially in small groups of patients with chronic gastrointestinal disorders such as Crohn’s disease. In these patients, radiation dose optimization is necessary and should follow the principles of justification, optimization and limitation. Currently, there are increasing numbers of medical specialists using fluoroscopy outside imaging departments and the use of fluoroscopy is currently greater than at any time in the past. This is partly explained by lack of education and training in radiation protection in this setting, and can result in increased radiation risk to patients and staff. Radiation protection and fluoroscopy facilities separate from radiology departments The extent of the problem with radiation protection in endoscopy suites can vary greatly from one jurisdiction to another [1, 2]. In some countries, there is no database of fluoroscopic equipment located outside radiology departments. As a result, staff in endoscopy suites need enhanced radiation protection education and need to routinely utilize radiation protection tools (e. There is huge variation, between institutions and between countries, in the level of involvement of radiologists and medical physicists in radiation protection for endoscopic procedures. Potential risk areas In some hospitals and in some jurisdictions, there may be a lack of radiation protection culture, with a paucity of patient and staff dose monitoring [1, 2]. There may be poor quality control of fluoroscopic equipment with risk for incidental accidental high exposures or routine overexposures affecting patients and staff. Poor radiation shielding, including lead flaps and poor maintenance of radiation protection equipment, can also be associated with additional risks. Radiation dose to patients in endoscopic procedures Shielding systems to protect staff should be optimized to reduce dose, but must not interfere with performance of clinical tasks. Scheduled periodic testing of fluoroscopic equipment can provide confidence in equipment safety [1, 2]. Equipment factors — Under-couch tubes reduce scattered radiation and exposure to operators, staff and patients. Image hold and image capture options also represent very important features of modern fluoroscopy which can reduce dose and should be used where feasible. Procedure related factors There are many important steps which can be taken to reduce radiation exposure, including the careful use of collimation to reduce area of exposure, limiting the number of radiographic images, using magnification only when really necessary and avoiding steep angulations of the X ray tube [1, 2]. The X ray tube should be as far as possible and image receptor as close as possible to the patient. In addition, the radiation field should be limited carefully to the parts of the body being investigated. Staff doses at endoscopic retrograde cholangiopancreatography Average effective doses of 2–70 μSv per procedure have been reported for endoscopists wearing a lead apron [1, 2]. Lead aprons provide protection; however, there can be substantial doses to unshielded parts such as the fingers and eyes. Use of ceiling mounted shielding, and lead rubber flaps mounted on pedestals that are mobile, should be mandatory and staff should be educated in how to use them effectively.

These are also seen in Lewy many of the normal methods of sterilisation including body dementia discount 75 mg endep overnight delivery. There are other (β secretase) has been cloned order endep 75 mg visa, leading to hopes of other prion diseases such as targeted therapies buy 50mg endep fast delivery. Rapidly progressive dementia caused by a prion (pro- It is currently thought that a normal glycoprotein teinaceous infectious agent), described in 1982 by neu- in the brain (the function of which is unknown) rologist Stanley Prusiner undergoes conformational change to become prion pro- tein (PrP). This abnormally conformed protein is resis- tant to digestion by proteases and tends to form poly- Incidence mers. In familial cases, it appears More common in certain parts of the world due to fa- that the abnormal protein arises spontaneously due to a milial cases, e. It is in- volved in glycolytic pathways, mediating carbohydrate Microscopy metabolism. Deficiency leads to ischaemic damage to Neuronalloss,increaseinglialcells,lackofinflammation the brainstem. Other signs include ptosis, abnormal pupillary re- There are raised levels of a normal intraneuronal protein actions and altered consciousness. There is no reliable method of confirming diagnosis Occasionally, patients present with Korsakoff’s, with except by brain biopsy or postmortem. Patients may have a peripheral neuropathy due to other Prognosis nutritional deficiencies. Investigations Diagnosis is usually clinical, and on response to thi- Wernicke–Korsakoff syndrome amine. Erythocytetransketolaseactivityandbloodpyru- Definition vate are increased, but treatment should not be delayed Wernicke’s encephalopathy is a triad of confusion, oph- whilst waiting for results. Korsakoff syndrome is a loss of short-term memory and disinhibition, leading to con- Management fabulation. Aetiology Usually seen in alcoholics, but may also be seen in star- Prognosis vation, malnutrition, parenteral feeding without vita- Recovery is prompt in most cases, occurring within min supplements and chronic vomiting, e. Thiamine is present in fortified wheat chronic cases when the diagnosis is delayed. Definition r Absent cough and gag reflexes on pharyngeal, laryn- This is defined as ‘irreversible loss of the capacity for geal or tracheal stimulation. Any intracranial cause or a systemic cause Apnoea testing such as severe, prolonged hypoxia or hypotension can The patient is pre-ventilated with 100% oxygen and con- lead to brainstem death. Although If all the above criteria are fulfilled, the patient is diag- patients who fulfil these criteria can be kept alive by ven- nosed as brainstem dead, and ventilation may be with- tilation, eventually they will die from other causes. Patients with some evidence of brainstem activity may Clinical features still have a very poor prognosis. Death may occur due to In order to diagnose brainstem death several criteria cardiovascular collapse, e. However, ifthepatientremainsstable,butwithverylittle Priortobrainstemtesting,thefollowingpreconditions brain function, it may be appropriate to withdraw life must be fulfilled: r prolonging treatment, but this may require application There must be a diagnosis for the cause of the irre- to the courts. Parkinson’s disease and other r There must be no possibility of drug intoxication, movement disorders including any recent use of anaesthetic agents or paralysing agents. Parkinson’s disease r Hypothermia should be excluded and body tempera- ture must be >35◦C. Definition r There must be no significant metabolic, endocrine or Acommon degenerative disease of dopaminergic neu- electrolyte disturbance causing or contributing to the rones characterised by tremor, bradykinesia, rigidity and coma. This should be carried out by two experienced clinicians (one a consultant, another an experienced registrar or consultant) on two separate occasions 12 hours apart. Age These tests are designed to show that all brainstem re- Prevalence increases sharply with age. M slightly > F Chapter 7: Parkinson’s disease and other movement disorders 319 Geography r Other features include facial masking, dribbling of Common worldwide saliva, dysphagia, dysphonia and dysarthria – quiet monotonous speech with a tendency to peter out with continued effort. There is little known about the aetiology r Nicotine: Some epidemiological evidence suggests a decreased risk in smokers, but that may be due to Macroscopy/microscopy younger death in this group. Loss of pigment from the substantia nigra due to the r Therearesomefamilialforms,particularlyearly-onset death of melanin-containing dopaminergic neurones. Surviving cells contain spherical inclusions called Lewy bodies – hyaline centres with a pale halo. Pathophysiology Investigations The substantia nigra is one of the nuclei of the basal Clinical diagnosis, but other parkinsonian syndromes ganglia. Biochemically This includes a multidisciplinary approach for this there is a loss of dopamine and melanin in the striatum chronic disease, including education, support, physio- which correlates with the degree of akinesia. The basal r Levodopa, a dopamine precursor, is the most im- ganglia project via a dopaminergic pathway to the thala- portant agent used. It is given with an peripheral mus and then to the cerebral cortex, where it integrates dopa-decarboxylase inhibitor (such as carbidopa or withthepyramidalpathwaytocontrolmovement. Hence benserazide) to prevent the conversion of l-dopa to it is sometimes called the extrapyramidal system. Lev- Clinical features odopa exerts most effect on bradykinesia and rigidity The features are asymmetrical. It is in- ‘on’ periods when they have a good response to the creased by emotion and decreased on action. Increased tone alone may cause lead-pipe movements called dyskinesias, or painful dystonias rigidity. These appear to be due to the progressive (slowness of movement) and hypokinesia (reduced degeneration of the neuronal terminals, such that size of movement). When walking there may be a reduced arm ii ‘On/off’ phenomenon may be treated by increas- swing and increased pill-rolling tremor. There is a loss of postural tral metabolism of l-dopa and dopamine, so giving reflexes. These may be considered first-line treat- prompt the search for another cause of the symp- ment in young patients. They have a neuroprotective toms, as other causes of parkinsonism do not usually effect in vitro. This can be redressed by anticholinergic drugs such as ben- Other causes of Parkinsonism ztropine and procyclidine. They tend only to be used in mild tremor, and they do not help with akinesia or Definition gait. There are certain disorders that mimic idiopathic r Selegiline is a monoamine oxidase B inhibitor which Parkinson’s disease, i. There are also specific ‘Parkinson’s plus’ syndromes r Depression is common, difficult to treat and makes where there is evidence of other neurological deficit: Parkinson’s disease worse. However surgery carries the risk of haem- rioration, with marked postural instability, frequent orrhage or infarction in 4%, with a 1% mortality. In later disease, be- r High frequency deep brain stimulation suppresses havioural changes such as emotional lability and per- neuronal activity. Bilateral subthalamic nucleus stim- sonality changes, disordered sleep and cognitive loss ulation or globus pallidus stimulation is most useful are features, which may lead to the initial diagnosis of in those with difficulty with the on-off phenomenon, dementia. Pathophysiology Cerebrovascular parkinsonism is likely to be due to pro- Prognosis gressive loss of dopaminergic neurons due to small vessel The course of Parkinson’s disease is very variable. Drugs which interfere with the dopamine path- averagesurvival is ∼10 years from onset of symptoms.

Without malnutrition cheap endep 25 mg line, extremes of healthy immunised treatment buy endep pills in toronto, extensive caseating lesions develop rapidly buy 10 mg endep otc, age, intercurrent disease individual leading to a high mortality. This disease is sometimes Use of appropriate antibiotics called ‘galloping consumption’. By that time there may be no evidence of tu- comesinfectedbymiliarydisseminationwithmultiple berculosis elsewhere. If a lesion erodes a pulmonary vein, there may be systemic miliary dissemination, for ex- Clinical features ample to the meninges, spleen, liver, the choroid and 1 Primary tuberculosis is usually asymptomatic, occa- the bone marrow. The hypersensitivity reaction may produce patient mounts a good immune response, organisms atransient pleural effusion or erythema nodosum. The outstanding Chapter 3: Respiratory infections 105 features are fever (drenching night sweats are rare) be normal, as tubercles are not visible until they are and cough productive of mucoid, purulent or blood 1–2 mm. Microscopy Formal culture of material is the only way of accu- The characteristic lesion, the tubercle (granuloma) con- rately determining virulence and antibiotic sensitivity sists of a central area of caseous tissue necrosis within and should be attempted in every case, results may which are viable mycobacteria. It relies on the hypersensitivity reaction, usually heals spontaneously but occasionally may per- and is rarely helpful in the diagnosis of tuberculosis: sist giving rise to bronchiectasis particularly of the i The Tine test and Heaf test are for screening: 4/6 middle lobe (Brock’s Syndrome). If the spots are confluent, logicalfractures,particularlyofthespinetogetherwith the test is positive, indicating exposure. The reaction is read at Investigations 48–72 hours and is said to be positive if the indura- r An abnormal chest X-ray is often found incidentally tion is 10 mm or more in diameter, negative if less in the absence of symptoms, but it is very rare for a than 5 mm. The X-ray shows purified protein derivative this can indicate active patchy or nodular shadowing in the upper zone with infection requiring treatment. In an immunocom- fibrosis and loss of volume; calcification and cavita- promised host (such as chronic renal failure, lym- tion may also be present. Human immunity depends largely on the haemag- niazid, ethambutol and pyrazinamide, and a further glutinin (H) antigen and the neuraminidase (N) antigen 4months of rifampicin and isoniazid alone. Major shifts in these antigenic re- taken 30 minutes before breakfast to aid absorption. Thesecancauseapandemic,whereasantigenicdrift organism is sensitive for a full 6 months to avoid de- causes the milder annual epidemics. Other upper and lower respiratory symptoms to6weeks after birth (without prior skin testing) in ar- may develop. Individuals are infective for 1 day prior to eas with a high incidence of tuberculosis. Less commonly, secondary Five per cent of patients do not respond to therapy, only Staph. Influenza A causes worldwide annual epidemics and is Retrospective diagnosis can be made by a rise in spe- infamous for the much rarer pandemics, the most seri- cificcomplement-fixingantibodyorhaemagglutininan- ous of which occurred in 1918 when ∼40 million people tibody measured 2 weeks apart, but this is usually un- died worldwide. Spread is by respiratory r Bed rest, antipyretics such as paracetamol for symp- droplets. Chapter 3: Respiratory infections 107 r The neuraminidase inhibitors zanamivir and os- emboli, e. Clinical features They are particularly indicated in the elderly, those Patients present with worsening features of pneumonia, with underlying respiratory disease such as chronic usually with a swinging pyrexia, and can be severely ill. Some are manufactured in strates one or more round opacities often with a fluid chickembryosandtheseshouldnotbegiventoanyone level. Routine vaccination is reserved for bronchoscopy may be necessary to exclude obstruction, susceptible people with chronic heart, lung or renal to look for underlying carcinoma, and to obtain biopsies disease,diabetes,immunosuppressionandtheelderly. Echocardiogram should be considered to look for infec- These predications depend on global surveillance or- tive endocarditis. This surveillance depends on viruses being cultured Complication and therefore on nose/throat swabs being taken and Breach of the pleura results in an empyema. Management Lung abscess Posturaldrainage,physiotherapyandaprolongedcourse of appropriate antibiotics to cover both aerobic and Definition anaerobic organisms will resolve most smaller ab- Localisedinfectionanddestructionoflungtissueleading scesses. Largerabscessesmayrequirerepeatedaspiration, to acollection of pus within the lung. Organismswhichcausecav- Definition itation and hence lung abscess include Staphylococcus Thereareessentiallythreepatternsof lungdiseasecaused and Klebsiella. Pathophysiology Aetiology The abscess may form during the course of an acute It is a filamentous fungus, the spores (5 µmindiame- pneumonia, or chronically in partially treated pneu- ter) are ubiquitously present in the atmosphere. The pattern of disease that arises depends 108 Chapter 3: Respiratory system on the degree of tissue invasiveness, the dose inhaled and Aspergilloma the level of the host’s defence. This results from Aspergillus growing within an area of previously damaged lung such as an old tuberculous Allergic bronchopulmonary aspergillosis cavity (sometimes called a mycetoma). Seen on X-ray as a round lesion with an air ‘halo’ above i Initially it causes bronchospasm which commonly it. In immunosuppressed individuals with a low granulo- iii Chronic infection and inflammation leads to irre- cyte count, the organism may proliferate causing a severe versible dilatation of the bronchi (classically proximal pneumonia, causing necrosis and infarction of the lung. The organisms are present as masses of hyphae invad- iv If left untreated progressive pulmonary fibrosis may ing lung tissue and often involving vessel walls. Investigation Theperipheralbloodeosinophilcountisraised,andspu- Management tum may show eosinophilia and mycelia. Eosinophilic Invasive aspergillosis is treated with intravenous am- pneumonia causes transient lung shadows on chest X- photericin B (often requiring liposomal preparations ray. Itraconazole and voriconazole have been used more re- Lung function testing confirms reversible obstruction in cently but current studies comparing efficacy with am- all cases, and may show reduced lung volumes in cases photericin B have yet to prove definitive. Management Obstructive lung disorders Generally it is not possible to eradicate the fungus. Itra- conazole has been shown to modify the immunologic Asthma activation and improves clinical outcome, at least over the period of 16 weeks. Oral corticosteroids are used to Definition suppress inflammation until clinically and radiograph- A disease with airways obstruction (which is reversible ically returned to normal. Maintenance steroid therapy spontaneously or with treatment), airway inflammation may be required subsequently. The asthmatic compo- and increased airway responsiveness to a number of nent is treated as per asthma guidelines. Chapter 3: Obstructive lung disorders 109 Incidence Pathophysiology 20% of children, 5–14% of adults, increasing in preva- The clinical picture of asthma results from mixed acute lence. With time this repeated stimula- Can present at any age, predominantly in children. They secrete mediators of acute and 2 Intrinsic asthma tends to present later in life. There is chronic inflammation including enzymes and oxygen no identifiable allergic precipitant. Patients with occupational asthma from the listed causes are entitled to compensation under in- inflammation recruiting and activating fibroblasts dustrial injuries legislation in the United Kingdom. They also lead, through r Forall patients, non-specific irritant trigger fac- mechanisms which are not yet clearly defined, to tors include viral infections, cold air, exercise, bronchialhyperresponsiveness–anexaggeratedbron- emotion, atmospheric pollution, dust, vapours, choconstrictor response to non-specific insults to the fumes and drugs particularly nonsteroidal anti- airways. The pattern of airway reaction following inhalation of an allergen: i An acute reaction occurring within minutes, peaking Table3.

About a month later buy endep without prescription, 23 January 1896 quality endep 25 mg, he gave a lecture on the new rays to the Physical Medical Society of Würzburg purchase endep with american express. During the meeting Roentgen took an X-ray photograph of the hand of the anatomist A. After this had been done, von Kölliker proposed that the new rays should be called “Roentgen’s rays”, and this suggestion was approved with great enthusiasm by the audience. The development from this frst photo was rapid both with regard to technology and use. We shall give a short history of the development that resulted in sharper and much better pictures. In an ordinary x-ray photo the object is placed between the x-ray source and the detector (for example flm). The picture is based on the x-rays that penetrate the object and hit the detector – and yields the electron density in the object. The last one is observed using a digital flter to enhance the details and reduce the noise. He is frequently cited as one of the most im- portant contributors to the birth of commercial electric- ity and is known for his many revolutionary develop- ments in the feld of electromagnetism in the late 19th and early 20th centuries. We can mention that he de- signed the frst hydroelectric power plant in Niagara Falls in 1895. Electrons were emitted and Nikola Tesla accelerated by the electrical feld in his “Tesla coil”. Tesla managed to obtain images of the human body with this radiation – the shadowgraphs. He also sent some of his images to Roentgen shortly after Roentgen published his discov- ery. Tesla gave Roentgen full credit for the fnding and never attempted to proclaim priority. In the magazine “Electrical Review” for 1896 some X-ray observations by Tesla were pub- lished. He described some clinical benefts of x-rays – for example; determination of for- eign body position and detection of lung diseases. Furthermore, during the next 50 years x-ray pictures and fuoroscopy played an important role in the treatment of tuberculosis. In the period before streptomycin (1947) the only treatment was pneumothorax – an attempt to let the lung rest by accumulation of air in the pleural cavity – and the lung more or less collapsed. We can note that no dosimetry was carried out at the time – and the doses now quoted are very much speculations (see page 210). The idea was to introduce elements that could absorb ef- fciently the x-rays and thus enhance the contrast. The main absorption mechanism is the photoelectric effect – which varies consider- ably with the atomic number (approximately as Z4). In a complex mixture of elements like that found in the organs of a patient, the degree of attenuation varies with the average of the atomic number of all the atoms involved. If two organs have similar densities and similar average atomic numbers, it is not possible to distinguish them on a radiograph, because no natural contrast exists. For example, it is not possible to identify blood vessels within an organ, or to demonstrate the internal structure of the kidney, without artifcially altering the electron density and absorption. In the period from 1931 until it was stopped2 2 – 10 million patients worldwide have been treated with Thorotrast. In 1910 barium sulfate was introduced as contrast agent for gastrointestinal diagnosis. In 1924 the frst imaging of the gallbladder, bile duct and blood vessels took place. This tube was superior to other tubes at the time because of; 1) its high vacuum and 2) a heated flament as the source for electrons. He was able to show that a narrow catheter could be advanced from a vein in the arm into the right atrium of the heart, a distance of almost two-thirds of a meter. Obviously, this constituted a remarkable advance – and could be visual- ized by contrast compounds. This opened the way for angiography which al- lowed the routine imaging of blood vessels and the heart. In connection to this “break-through” in medical im- aging we have to mention the forerunner of the tech- nique called “planigraphy”. In 1948 Marius Kolsrud at the University of Oslo pre- sented a master thesis with the title; Godfrey Hounsfeld Allan Cormack Røntgen-skikt-avbildning. Kolsrud made equipment that made it possible to take x-ray pictures of a single plane in the object. Consequently, structures in the focal plane appear sharper, while structures in other planes appear blurred. It is thus possible to select different focal planes which contain the structures of interest. This method was used for chest x-ray pictures in connection with tuberculo- sis for a number of years. This technique uses x-ray fuo- roscopy to guide the compression of plaques and minimize the dangerous constriction of the heart vessels. The signal from the x-ray system is con- verted to a digital picture which can then be enhanced for clearer diagnosis Andreas Gruentzig and stored digitally for future review. The physical basis for an x-ray picture The x-ray picture is a shadow picture of the part of the body that is between the x-ray tube and the flm. Only the x-ray photons that penetrate the object and reach the flm can give a signal or blacken- ing of the flm. To see into the body we must have “something” that can penetrate the body – come out again – and give information. The fgure below is an attempt to illustrate the main points for making an x-ray photo. The two drawings – one vertical and one hor- Incoming x-ray photons izontal – are attempts to illustrate the basic principles for an x-ray photo. Absorber Part of the body Transmitted Electron photons The x-rays is absorbed according to the electron density Incoming photons Detector Scattered flm, fuoeresent screen, etc. The x-ray source On page 8 we described the basic principles for the formation of x-rays – or rather bremstrahlung. When electrons with high energy smash into the “anticathode” – a tiny part of the energy is trans- formed into radiation. This implies that the x-ray photons formed, may have a number of different energies – in fact a whole spectrum is formed (the “Initial spectrum” in the fgure below).

Administration’s Substance Abuse Treatment Facility Locator at http://findtreatment order endep once a day. Acknowledgements The authors would like to thank Jennifer Manlove at Child Trends for her careful review of and helpful comments on this brief purchase discount endep on line. Monitoring the Future order endep 25mg without a prescription, national results on adolescent drug use: overview of key findings, 2011. Results from the 2009 National Survey on Drug Use and Health: Volume I summary of national findings. Just say “I don’t”: lack of concordance between teen report and biological measures of drug use. Nonmedical prescription drug use in a nationally representative sample of adolescents. General and specific predictors of behavioral and emotional problems among adolescents. Early substance use and school achievement: an examination of Latino, white, and African American youth. What works for preventing and stopping substance use in adolescents: lessons from experimental evaluations of programs and interventions. The American Red Cross Scientific Advisory Council is a panel of nationally recognized experts drawn from a wide variety of scientific, medical and academic disciplines. The American Red Cross is a not-for-profit organization that depends on volunteers and the generosity of the American public to perform its mission. The emergency care procedures outlined in the program materials reflect the standard of knowledge and accepted emergency practices in the United States at the time this manual was published. It is the reader’s responsibility to stay informed of changes in emergency care procedures. The following materials (including downloadable electronic materials, as applicable) including all content, graphics, images and logos, are copyrighted by, and the exclusive property of, The American National Red Cross (“Red Cross”). Unless otherwise indicated in writing by the Red Cross, the Red Cross grants you (“Recipient”) the limited right to download, print, photocopy and use the electronic materials only for use in conjunction with teaching or preparing to teach a Red Cross course by individuals or entities expressly authorized by the Red Cross, subject to the following restrictions: • The Recipient is prohibited from creating new electronic versions of the materials. The Red Cross does not permit its materials to be reproduced or published without advance written permission from the Red Cross. To request permission to reproduce or publish Red Cross materials, please submit your written request to The American National Red Cross. The Red Cross emblem, American Red Cross® and the American Red Cross logo are trademarks of The American National Red Cross and protected by various national statutes. The American Red Cross Scientific Advisory Council is a panel of nationally recognized experts drawn from a wide variety of scientific, medical and academic disciplines. Fox, PhD Aquatics Sub-Council Chair Regional Chair of Disaster Mental Services, Associate Clinical Professor of Orthopedic American Red Cross Northeast New York Surgery, University of Florida Medical Region School Medical Advisor, U. Claire’s Health Technical Committee on Bather Supervision System and Lifeguarding Vice Chair, Technical Committee on Jeffrey L. Thank you to Fire Chief Richard Bowers, Assistant Chief Garrett Dyer and Deputy Chief Manuel Barrero for their willingness to accommodate the American Red Cross. Bailey and Battalion Chief Jerome Williams for coordinating volunteers and resources, and ensuring the highest level of participation in this program’s pilot and video production. More information on the science of the course content can be found at the following websites: Ÿ www. The information gathered from these steps is used to determine your immediate course of action. Your actions during emergency situations are often critical and may determine whether a seriously ill or injured patient survives. To learn more about your duty to respond and legal considerations, see Section 3: Additional Topics. When called to emergencies, you must keep in mind a few critical steps for your safety, the safety of your team, as well as the patient and bystanders. As part of your duty to respond, you must size up the scene to determine if the situation is safe, how many patients are involved and the nature of the illness/mechanism of injury; gather an initial impression; and call for additional resources including any additional equipment and providers as needed. Using Your Senses Recognizing an emergency requires you to size up the scene using your senses such as hearing, sight and smell to acquire a complete picture of the situation. Using your senses can give you clues to what happened and any potential dangers that may exist such as the smell of gas or the sound of a downed electrical wire sparking on the roadway. Before you can help an ill or injured patient, make sure that the scene is safe for you and any bystanders, and gather an initial impression of the situation. Basic Life Support for Healthcare Providers Handbook 5 - Critically think about the situation and ask yourself if what you see makes sense. Is this a traumatic situation or could this crash have been caused by a medical emergency while the patient was driving? Initial Impression Before you reach the patient, continue to use your senses to obtain an initial impression about the illness or injury and identify what may be wrong. Look for signs that may indicate a life-threatening emergency such as unconsciousness, abnormal skin color or life-threatening bleeding. If you see life- threatening bleeding, use any available resources to control the hemorrhage including a tourniquet if one is available and you are trained. Primary Assessment of the Unresponsive Adult Patient After completing the scene size-up and determining that it is safe to approach the patient, you need to conduct a primary assessment. This assessment involves three major areas: assessing the level of consciousness, breathing and circulation. This may be obvious from your scene size-up and initial impression—for example, the patient may be able to speak to you, or he or she may be moaning, crying, making some other noise or moving around. If the 6 American Red Cross patient is responsive, obtain the patient’s consent, reassure him or her and try to find out what happened. To check for responsiveness, tap the patient on the shoulder and shout, “Are you okay? Remember that a response to verbal or painful stimuli may be subtle, such as some slight patient movement or momentary eye opening that occurs as you speak to the patient or apply a painful stimulus such as a tap to the shoulder. Airway Once you have assessed the patient’s level of consciousness, evaluate the patient’s airway. For a patient who is unresponsive, make sure that he or she is in a supine (face-up) position to effectively evaluate the airway. If the patient is face-down, you must roll the patient onto his or her back, taking care not to create or worsen an injury. If the patient is unresponsive and his or her airway is not open, you need to open the airway. Two methods may be used: ŸŸ Head-tilt/chin-lift technique ŸŸ Modified jaw-thrust maneuver, if a head, neck or spinal injury is suspected Head-tilt/chin-lift technique To perform the head-tilt/chin lift technique on an adult: ŸŸ Press down on the forehead while pulling up on the bony part of the chin with two to three fingers of the other hand. Basic Life Support for Healthcare Providers Handbook 7 Modified jaw-thrust maneuver The modified jaw-thrust maneuver is used to open the airway when a patient is suspected of having a head, neck or spinal injury.

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