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The main indication for this procedure is to perform endomyocardial biopsy cheap 250mg flagyl fast delivery, which is invasive and has higher complication rate in younger age groups purchase 200 mg flagyl amex. It is estimated that about one quarter of pediatric patient cases of dilated cardiomyopathy is caused by acute myocarditis. The differential diagnosis of the presenting manifestations in infants include sepsis, metabolic disturbances, inherited metabolic disorders, mito- chondrial myopathies and anomalous origin of the left coronary artery from the pul- monary artery. The differential diagnosis in older children includes idiopathic and inherited cardiomyopathy, chronic tachyarrhythmia, and connective tissue diseases. This includes use of intravenous inotropic support with Dopamine, Dobutamine, and Milrinone. Intravenous after-load reducing agents like sodium nitroprusside are used in the acute intensive care setting. Diuretic therapy is usually used for those patients who present with congestive symptoms and signs. Oral therapy with afterload reducing agents is used in patients with more stable clinical condition who have persistent left ventricular dysfunction. Angiotensin- converting enzyme inhibitors such as captopril and enalapril, b-adrenergic blockers, and anticoagulant or antiplatelet medications are the main treatment modalities. Bed rest in the acute stage with close observation is the mainstay of treatment in mild and asymptomatic cases. Digitalis is avoided during the acute stage of the inflammation due to possible cardiac side effects such as ventricular arrhythmias, although it can be used in the chronic stage of the disease or in those who progress to dilated cardiomyopathy. Other therapies, such as the use of immunosuppressive therapy and immuno- modulating agents like intravenous immunoglobulin is still controversial. So far studies showed no benefit of steroids or other immunosuppressants in the long-term outcome of the disease. Patients who present with fulminant myocarditis or intractable arrhythmias may need mechanical support like extracorporeal membrane oxygenation, ventricular assist devices, or even heart transplantation. Prognosis The long-term outcome of patients with acute myocarditis varies by the initial pre- sentation. Torchen Patients who present with acute fulminant myocarditis have the best recovery outcome if they survive the initial acute stage, with full recovery of ventricular function in >90% of patients in one series. Overall, about 1/2 to 2/3 of pediatric patients with myocarditis show complete recovery, 10% have incomplete recovery and up to 25% either die or require heart transplantation. Case Scenarios Case 1 History: A previously healthy 3-year-old boy is brought to the emergency room because he has been having abdominal pain and vomiting for the last 2 days. Physical examination: The patient’s physical examination shows that he has mild dehydration. Differential diagnosis: Based on the information obtained so far, it appears that this child has some degree of heart failure, based on the findings of tachycardia, tachyp- nea, hepatomegaly, cardiomegaly, and increased vascular markings on chest X-ray. Other causes such as endocarditis, myocarditis, or pericarditis must be considered. Final diagnosis: An echocardiogram is performed which shows dilatation of the left ventricle with decreased systolic function and moderate mitral regurgitation. It is usually preceded by a viral prodrome of either upper respiratory tract infection or gastro- enteritis. He recovers from the acute phase of the disease and is then discharged home on an oral ace inhibitor, aspirin, and a diuretic. Case 2 History: An 8-month-old infant is brought to the emergency room by ambulance after what is thought to be a brief seizure episode. This infant was previously healthy and was playing at home when she suddenly became limp and unresponsive for a few seconds prior to regaining consciousness. She had a preceding upper respiratory tract infection and low-grade fever 5 days prior to this episode. Physical examination: On physical exam, the patient is fully awake and alert with mild tachypnea. Investigative studies: Laboratory workup shows mildly elevated white cell count, with lymphocytic predominance. Differential diagnosis: The differential diagnosis remains quite broad at this time. However, the anion gap metabolic acidosis is more concerning; causes including hypoperfusion leading to lactic acidosis, diabetic ketoacidosis, and toxic ingestion must be considered. During this observation period, she has another episode dur- ing which she becomes pale, dusky, and limp. An echocardiogram performed upon arrival to the tertiary care center is significant for dilatation of the left ventricle with decreased systolic function. Assessment: This is a less common presentation of acute myocarditis presenting with loss of consciousness secondary to ventricular arrhythmias.

In all buy flagyl 400mg low cost, 21 medical colleges have been identified for establishing / up-gradation of P buy flagyl 200 mg with mastercard. The scheme involves signing of memorandum of understanding with State Governments for providing adequate space and logistic support in medical colleges and designation of Nodal Officer and grant for financial assistance for procurement of equipment and engagement of manpower on contractual basis as shown in the table below: 1 Silchar Med. Despite the above constraints, the challenge for building up capacity for providing quality in rehabilitation services will have to be carried forward vigorously in the years to come as anticipated as it may take number of years or considerable time to harness such services which are different from other types of health services in the Health Care System. Patient Safety Programme There have been some initiatives for safety of patients seeking health care services in the Public Sector as given below: • Patient Safety committees have been formed in three central government institutions in Delhi namely Dr Ram Manohar Lohia Hospital, Safdarjung Hospital and Lady Harding Medical College & associated Hospitals. The committee is headed by Medical Superintendent / Additional Medical Superintendent. Beside Hospital experts, the members of committee also include representative of a Non Govt. These hospitals conduct meetings of their patient safety committees to review the various patient safety issues, adverse events reported, actions taken and maintain records of all the meetings of their patient safety committees. Self learning modules in the area of Health Care Waste Management for doctors, nurses and paramedical and Group D employees have been developed. Sofar more than 60 medical colleges and tertiary care hospitals in public as well as private sector have been trained in these workshops. Till now more than 400 healthcare professionals from these institutes including doctors (surgeon, physician, anaesthetist and microbiologist), administrators and nurses have participated in these workshops. Lessons Learnt: Broadly, across programmes, following experiences were observed and lessons learnt in th implementation of programmes, which need to be addressed during the 12 Plan: 1. Convergence and integration would be critical in implementation of large number of interventions which would require unified management structure at various levels. Costs borne by the affected individuals and families may be catastrophic as treatment is long term and expensive. Investments during the 11 Plan and earlier plans have been more on provision of medical services which have not been adequate in the public sector. Private sector has grown particularly in urban settings but is beyond the reach of the poor and middle sections of the society. While Government of India’s role will be policy formulation, population based multi-setoral interventions, technical and financial th support, the onus of implementation will be with the States. To ensure convergence and integration with public health services, a decentralized approach is proposed with District as the management unit for programs. Hereditary Blood Disorders (Sickle Cell Anaemia, Thalassemia, Haemophilia) (b) Programmes for Disability Prevention and Rehabilitation 13. To ensure universal coverage including rural population and underprivileged urban poor, the schemes will beimplemented through Public Sector Health System. Primary Health Care: Health promotion, screening , basic medical care, home based care & referral system 2. Tertiary Care for advanced treatment of complicated cases, radiotherapy for cancer, cardiac emergency including cardiac surgery, neurosurgery, organ transplantation etc. Health Promotion & Prevention: Legislation, Population based interventions, Behaviour Change Communication using mass media, mid-media and interpersonal counselling and public awareness programmes in different settings (Schools, Colleges, Work Places and Industry). To ensure convergence, common districts will be selected for all three major programmes. The schemes would be flexible to meet local requirements as there would be variation in prevalence and availability of existing health infrastructure. Cancer Cancer pattern is varied in different parts of the country with increasing urbanization, sedentary habits & life style behavior it is becoming a major life style problem. At this juncture the country is equipped with only 450 radiotherapy machines in 250 institutes, where as the requirement is 1160 (1 per million population). The experts felt that Cancer should be a notifiable disease for the whole country like the State of West Bengal. It is essential that at all levels of the health facilities there is availability and accessibility of facilities for prevention, early detection, diagnosis, treatment and follow up of common cancers. The common cancers namely Oral, breast & cervix cancers can be easily prevented and detected early with simple measures and appropriated training of health professionals. Awareness rd generation on early warning signals, risk factors will help reduce at lest 1/3 of the common cancers. Regular Oral Clinical/ Self/ Examination for prevention of Oral Cancers, regular Physical examination of the breasts for Breast Cancers and r will help in reducing the morbidity on common cancers. Palliative care is an important and essential part of cancer care therapy, at least 10% of the budget need to be earmarked for these services at level of cancer care services. For availability of health professionals at the districts it may be made mandatory that there be 1 year posting at district hospitals after completion of the courses in Oncology in Medical/Surgical/Radiotherapy/Medical Physicst after which the degrees would be provided.

In this case order 500mg flagyl otc, samples should be taken at as many separate sites as possible and then wait a minimum of 2 hours before resampling enough sites to get the required number of samples purchase flagyl 400mg with visa. Treatment technique: An enforceable procedure or level of technical performance which public water systems must follow to ensure control of a contaminant. Action level: The level of lead or copper which, if exceeded, triggers treatment or other requirements that a water system must follow. What does the membrane filter test analyze with regards to bacteriological sampling? Membrane Filter Technique: A standard test used for measuring coliform numbers (quantity) in water is the membrane filter technique. This technique involves filtering a known volume of water through a special sterile filter. These filters are made of nitrocellulose acetate and polycarbonate, are 150 μm thick, and have 0. A grid pattern is printed on these filter disks in order to facilitate colony counting. The filter is then carefully removed, placed in a sterile petri plate on a pad saturated with a liquid medium, and incubated for 20-24 hours at 37°C. One assumes that each bacterium trapped on the filter will then grow into a separate colony. By counting the colonies one can directly determine the number of bacteria in the water sample that was filtered. Total coliform colonies will be pink to dark red in color and will appear to have a golden green color. What do the following terms mean in relation to drinking water quality: disinfection, pathogenic, toxic, pH, aesthetic, culinary and potable. Disinfection: The chemical process of killing or inactivating most microorganisms in water. These include bacteria, viruses, cysts and anything capable of causing disease in humans, like cryptosporidiosis, typhoid, cholera and so on. There are other organisms that do not create disease, these are called non-pathogenic organisms. A pH of less than 7 is on the acid side of the scale with 0 as the point of greatest acid activity. A pH of more than 7 is on the basic (alkaline) side of the scale with 14 as the point of greatest basic activity. For example, the acidity of a sample with a pH of 5 is ten times greater than that of a sample with a pH of 6. A difference of 2 units, from 6 to 4, would mean that the acidity is one hundred times greater, and so on. Aesthetic: Attractive or appealing water or things in water that will not make you sick but may appear to change the water’s color or taste. Potable: Water that is free of objectionable pollution, contamination, or infective agents. Hardness: Water that contains high amounts of dissolved minerals, specifically calcium and magnesium. Ion Exchange: A method of water softening where hardness causing ions are exchanged with sodium ions; also effective in removing many inorganic contaminants such as nitrates, copper, and lead; and treating aesthetic water problems. What is Escherichia Coliform and what does it indicate in relation to drinking water? If total coliform is present, the sample will also be tested for either fecal coliform or E. Hydrogen sulfide is a gas which, when dissolved in water, gives it a “rotten egg” odor. Chlorination will remove this gas from the water but the effectiveness of the chlorine for disinfection is lessened. When Hydrogen sulfide reacts with chlorine, it produces Sulfuric acid and elemental Sulfur: It is therefore recommended that aeration be applied prior to the addition of chlorine for the most effective disinfection. Why is it important to know what the turbidity of the water is when using chlorine? This log-reduction terminology was developed by engineers as a way to express levels of decreased biological contamination in water by factors of 10 that could be easily converted to percent reduction. The most commonly used logarithmic base is 10 because it is compatible with our base-10 decimal system. The log of 10 in the base 10 logarithmic system is 1 and the log of 100 is 2, with the log of 1000 being 3, etc. A 1-log reduction is nine out of 10 and would be equivalent to a 90 percent reduction. A 2-log reduction would be 99 out of 100 or 99 percent reduction and a 3-log reduction would be 999 out of 1000 or 99. What are the turbidity requirements for Direct and Conventional filtration plants? Conventional filtration is defined as a series of processes including coagulation, flocculation, sedimentation, and filtration resulting in substantial particulate removal.

Existing Risk factors data indicates a wide variation in prevalence rates • Recipients of unscreened blood order 250 mg flagyl with mastercard, blood products from region to region cheap 400mg flagyl amex, with some countries in and organ transplants Africa, Eastern Mediterranean, South-East Asia and • Intravenous drug users Western Pacific having high prevalence rates. It should • Healthcare workers be noted that seroprevelance studies taken from each • Those undergoing any invasive procedure such country may involve different population groups and as skin piercing and tattooing may not be entirely representative. Patients should be advised to see a doctor or attend a health Prevention of spread facility every 6–12 months so that their liver Patients should be informed and advised regarding function can be monitored. Patients should be advised not to share to cirrhosis are also less likely to respond to household items such as razors or toothbrushes. Patients suitable for therapy • Those with chronic infection It is recommended that screening should be • When liver biopsy shows evidence of fibrosis and accompanied by pre and post test counselling. The low risk of sexual and Risk factors more likely to be associated with household transmission should be discussed. Advice and • A high viral load information should be realistic and appropriate to • Male the individual. For patients who go on to develop liver cancer, the outlook is poor, but chemotherapy may prolong life for a few years. An understanding of modes of transmission can allow individuals to reduce their risk of contracting infection. Statement for the World Conference of obstacles to healthy development, World Health Ministers Responsible for Youth, Lisbon, http:// Organization report on infectious diseases, http:// www/unaids. Weekly Epidemiological Record, Hepatitis C - Global World Health Organization (1998). Aims of care: promote optimal respiratory function, alleviate cough, maintain adequate oxygenation. Possible interventions • Assess respiratory function and vital signs – findings should be recorded as a baseline assessment and 4 hourly thereafter. Changes in bowel habits Symptoms: diarrhoea related to opportunistic infection Possible causes: Cryptosporidosis, Kaposi’s sarcoma in G. The patient’s weight should be taken daily and an accurate record of fluid intake and output maintained. Gently pat the skin dry with a soft cloth or towel rather than wiping it to prevent fragile skin from tearing. Aims of care: prevent dehydration, alleviate distress, restore normal dietary habits. The patient’s weight should be recorded daily and an accurate record of fluid intake and output should be maintained. If the patient is very weak or unconscious it may be necessary for the nurse to provide oral care using gauze soaked in mouthwash or fresh water, and using the index finger, gently cleanse the mouth, applying petroleum jelly to lips to prevent cracking. Possible interventions • Assessment of vital signs and body temperature should be recorded 4 hourly. Aims of care: Alleviate pain Possible Interventions • Assess the location, type, intensity and persistence of the pain. Aims of care: minimise the effects of neurological dysfunction, maintain a safe environment. Possible Interventions • Assess baseline mental status, including the patient’s ability to understand. Speak in a calm and relaxed manner, give one instruction at a time, and repeat information as necessary. Aims of care: keep the patient well nourished, prevent further weight loss, attain normal body weight Possible interventions • Assess previous dietary patterns including food likes and dislikes and any known allergies. Aims of care: establish a trusting/therapeutic relationship, improve motivation and self esteem, reduce the risk of self harm. Aims of care: establish a relationship in which the patient feels able to discuss their concerns, reduce/alleviate anxiety. Possible interventions • Set time aside to spend with the patient and encourage them to express their worry by asking open-ended questions. Weakness and fatigue Possible causes: Weakness and fatigue are common during acute and in chronic end-stage liver disease. Aims of care: to ensure personal hygiene needs are met, to ensure patient comfort, to ensure adequate rest is achieved, to promote self care when appropriate. Possible interventions • Assist the patient with washing or bathing according to their needs and wishes • Assist the patient with toileting as the patient requires • Assist the patient in achieving a comfortable position to promote rest and sleep, whilst preventing risk of pressure sore development • Promote self care and independence when appropriate, assessing and reviewing the patients needs continuously. Aims of care: Ensure adequate intake of nutritional needs Possible interventions • Patients with nausea and vomiting may require intravenous fluids of glucose and saline. This may be necessary due to the increased protein catabolism that occurs with acute liver disease and it can promote liver tissue repair. Jaundice Impaired liver function inhibits the body’s ability to excrete bile salts normally. Excess bile salts are excreted and deposited in the skin resulting in jaundice and generalized itching. Possible interventions • Administer antipruritics as prescribed (often not very effective). Possible complications due to cirrhosis Ascities Damage to liver cells can cause disturbance in the bodies excretory system, causing fluid to accumulate in the abdominal cavity.